Mental wellbeing in people with dementia following Cognitive Stimulation Therapy: Innovative practice

Abstract

The benefits of Cognitive Stimulation Therapy in supporting cognitive functioning for people with dementia are well recognised. It has been proposed that Cognitive Stimulation Therapy may offer additional benefits in terms of a person’s sense of general wellbeing. A service evaluation of 60 participants attending Cognitive Stimulation Therapy groups was conducted using the Short Warwick-Edinburgh Mental Well-Being Scale. Although this evaluation did not demonstrate a significant difference between pre- and post-treatment scores (t = −1.75, df = −59, p = −0.085), there was a trend in participants’ reported optimism about the future and confidence. Recommendations about future research in relation to mental wellbeing in dementia care are discussed.

Keywords

Cognitive Stimulation Therapy dementia mental wellbeing psycho-social interventions quality of life

Introduction

Cognitive Stimulation Therapy is a non-pharmalogical group-based intervention (National Institute for Health and Care Excellence, 2011) which has been demonstrated to be beneficial to people with dementia (Olazaran et al., 2010). Its effects have been favourably compared to drug treatments in terms of supporting cognitive functioning (Spector et al., 2003). Cognitive Stimulation Therapy includes a range of different stimulating themes such as reminiscence of childhood, current affairs and word games that consist of a combination of group activities, discussion and individual-based tasks. It aims to promote the individual strengths of people with dementia (Spector, Gardner, & Orrell, 2011) and has received a wealth of support for its benefits, including: improvements in quality of life and activities of daily living, a reduction in depression (Woods, Thorgrimsen, Spector, Royan, & Orrell, 2006) and cognitive decline (Salthouse, 2006). The National Institute for Health and Care Excellence (2011), the body which provides national guidance and advice to improve health and social care in England, recommends that people with mild-to-moderate dementia of all types should be given the opportunity to participate in a structured group cognitive stimulation programme.

Although there has been an understandable emphasis on sustaining cognitive performance, there is growing interest in exploring quality of life as a key outcome in many aspects of dementia care (Woods et al., 2006), and is increasingly considered as an important indicator for assessing the effectiveness of treatments for people with dementia (Naglie, 2007). Quality of life is, however, a complex and often nebulous construct to define (Tennant et al., 2007), with over 200 definitions reported in the literature (Schalock, 2000). These include many components including physical, social and spiritual health (Whitehouse & Rabins, 1992); cognitive ability and general wellbeing (Naglie, 2007). In addition, the ways in which quality of life has been applied and conceptualised across a range of social, health and economic settings often blur with other concepts such as life satisfaction, happiness and health status.

Attempts to investigate links between quality of life and Cognitive Stimulation Therapy have been conducted. Woods et al. (2006) focused on quality of life pre- and post-receiving Cognitive Stimulation Therapy with people living in residential homes or attending day centres. Overall, participants showed improved perception of quality of life but this improvement was greater in women and those with low baseline measure of quality of life. Further research conducted by Wilson, Haddlesey, and Johal (2013) also investigated the effects of Cognitive Stimulation Therapy using the California Older Persons’ Pleasurable Events Schedule (Gallagher-Thompson, Thompson, & Rider, 2004) to assess quality of life pre- and post-intervention. Post-treatment, participants reported improved pleasure from increased levels of activity. Nonetheless, Wilson et al. (2013) had reservations that the California Older Persons’ Pleasurable Events Schedule measure might be regarded as ‘a reductionist measure for quality of life as a whole’ and acknowledged the relatively small sample size of their study. Earlier research by Ballard et al. (2001) highlighted that people with dementia might well have difficulty sustaining their attention when asked to answer all 66 questions included in the questionnaire. Measures that contain numerous items could limit their utility as a measure for people with cognitive impairment (Bäckman et al., 2004).

Given that the quality of life has so many facets, any reported improvements as a result of Cognitive Stimulation Therapy may be too broad a construct to qualify meaningfully. An alternative construct proposed by Tennant et al. (2007) is that of ‘mental wellbeing’. They define mental wellbeing as positive mental health encompassing both the hedonic perspective (a subjective feeling of happiness and life satisfaction) and a dimension of eudaimonia (related to a subjective sense of mastery, purpose and satisfaction within relationships and the environment). Mental wellbeing may instead identify elements more salient to people’s functioning whilst living with dementia. It has been suggested that wellbeing is more related to an individual’s perception of their current situation and aspirations (Emerson, 1985; Felce & Perry, 1995).

This construct of mental wellbeing may prove to be a valid concept for people with a neurological condition. If this study could demonstrate that alongside maintaining cognitive functioning, Cognitive Stimulation Therapy is also effective in improving mental wellbeing of people with dementia, the scope for Cognitive Stimulation Therapy could be extended. In line with previous research suggesting gender differences in response to Cognitive Stimulation Therapy (Woods et al., 2006), it also considered the role of gender in relation to mental wellbeing.

Method

Design

This service evaluation adopted a within group, repeated measures design. A positivistic epistemology informed the quantitative data collection which consisted of a self-completed questionnaire.

Participants

Participants were assessed and diagnosed by the Humber Memory Assessment Service which covers the city of Hull and the East Riding of Yorkshire. Each participant had their biopsychosocial needs discussed in a multidisciplinary formulation meeting, including their suitability for Cognitive Stimulation Therapy. Participants were offered Cognitive Stimulation Therapy during their diagnostic disclosure and were referred with their consent. The referral criteria for Cognitive Stimulation Therapy include a diagnosis of mild-to-moderate dementia, an ability to tolerate group situations and capacity to consent. The sample comprised 25 women and 35 men; 12 participants had vascular dementia; 27 participants had Alzheimer’s disease; 20 had mixed-type dementia and one participant had fronto-temporal dementia. Participants’ ages ranged between 63 and 97 years (mean age = −78 years). Seven participants dropped out of the Cognitive Stimulation Therapy before completing the full treatment (12%). This was attributed to either illness or disliking the content of the sessions.

Measures

Due to the limitations highlighted with the California Older Persons’ Pleasurable Events Schedule (Gallagher-Thompson et al., 2004), participants completed the Short Warwick-Edinburgh Mental Well-Being Scale (Stewart-Brown et al., 2009) which is a brief and robust outcome scale identified as a possible valid and reliable tool to measure mental wellbeing. It consists of seven positively phrased statements on mental wellbeing. It also aims to assess a person’s feelings of usefulness and closeness to others. Each statement is measured on a five-point Likert scale. The lowest attainable score is 7 and the maximum is 35. A higher score indicates a state of positive mental wellbeing.

Procedure

The Cognitive Stimulation Therapy manual recommends 14 sessions (Spector et al., 2003). However, due to patient feedback about the short length of the sessions, the programme was adjusted to allow for longer sessions of 90 minutes over a reduced 10-week course. The groups were held across Hull and East Riding in Community Healthcare Clinics. Sessions were facilitated by assistant psychologists under the supervision of clinical psychologists. Eight groups took place between October 2014 and September 2015. Data were collected at the start of the first session and again at the end of the last session.

Results

The mean scores of wellbeing on the Short Warwick-Edinburgh Mental Well-Being Scale showed an increase from baseline (pre-intervention) (M = −24.89, SD = −4.26) to post-intervention (M = −25.87, SD = −5.20). The data were found to be normally distributed; therefore, a paired samples t-test was utilised to test whether the differences were significant. The acceptable level of statistical significance was set as p < 0.05. The results of the t-test comparing pre- and post-intervention scores were not significant (t = −1.75, df = −59, p = −0.085).

Short Warwick-Edinburgh Mental Well-Being Scale individual item analysis

The differences between the individual items on the Short Warwick-Edinburgh Mental Well-Being Scale pre- and post-Cognitive Stimulation Therapy intervention were compared. The data were skewed; therefore, the Wilcoxon signed-rank test was used. The results of the Wilcoxon are presented in Table 1.

Table 1.

Individual items on the Short Warwick-Edinburgh Mental Well-Being Scale pre- and post-Cognitive Stimulation Therapy.

	Z	Asymp. Sig. (2-tailed)
Item 1: I’ve been feeling optimistic about the future	−2.09	0.036
Item 2: I’ve been feeling useful	−0.29	0.770
Item 3: I’ve been feeling relaxed	−3.35	0.001
Item 4: I’ve been dealing with problems well	−0.31	0.76
Item 5: I’ve been thinking clearly	−2.90	0.004
Item 6: I’ve been feeling close to other people	−1.19	0.23
Item 7: I’ve been able to make up my own mind about things	−0.68	0.50

There was a significant increase between pre- and post-Cognitive Stimulation Therapy intervention in items 1 (Z = −2.09, p = −0.036), 3 (Z = −3.35, p = −0.001) and 5 (Z = −2.90, p = −0.004). Items 2 (Z = −0.29, p = −0.77), 4 (Z = −0.31, p = −0.76), 6 (Z = −1.19, p = −0.23) and 7 (Z = −0.68, p = −0.50) showed a slight increase. However these were non-significant.

Gender

Gender differences for changes in mean Short Warwick-Edinburgh Mental Well-Being Scale scores were compared. Women showed a greater increase post-Cognitive Stimulation Therapy (M = −1.60, SD = −5.32) compared to men (M = −0.94, SD = −5.67). The Independent Samples T-test showed no significant difference in score fluctuation by gender (p = −0.65).

Discussion

The aim of this service evaluation was to investigate if Cognitive Stimulation Therapy has an effect beyond its primary aim of sustaining cognition and may offer unexplored benefits in terms of a person’s mental wellbeing.

The findings of this paper suggest that the construct of mental wellbeing is worthy of investigation in relation to benefiting people with dementia. Although this study failed to demonstrate a significant difference in pre- and post-intervention scores, there was a trend towards improved mental wellbeing post-Cognitive Stimulation Therapy. It may be that a larger sample might have demonstrated a stronger finding. Conversely, it was interesting that there was no overall sample reduction observed in mental wellbeing. Given that all participants had recently received a diagnosis of dementia, this finding might suggest that Cognitive Stimulation Therapy may offer some protection against the deleterious impact that a diagnosis of dementia can have.

A more detailed examination of the individual items on the Short Warwick-Edinburgh Mental Well-Being Scale was also conducted to ascertain whether any individual elements of mental wellbeing did change following Cognitive Stimulation Therapy. Significant improvements were found in three areas, including: ‘feeling optimistic about the future’, ‘feeling relaxed’ and ‘thinking more clearly’. The first statement ‘feeling optimistic about the future’ suggests that people perceive their life more positively following the treatment, which is consistent with previous research on the benefits of Cognitive Stimulation Therapy (Wilson et al., 2013). The second statement ‘feeling relaxed’ is consistent with Spector et al.’s (2011) qualitative study on the impact of Cognitive Stimulation Therapy where participants reported feeling more positive, relaxed and confident. The third statement ‘thinking more clearly’ may be linked to a person’s increased cognitive functioning which is consistent with previous research (Spector et al., 2003).

Other elements on the Short Warwick-Edinburgh Mental Well-Being Scale, such as feeling useful; the ability to deal with problems well; feeling closer to other people and decision-making all showed slight improvements post-Cognitive Stimulation Therapy. However, these were not found to be significant. This would suggest that the eudaimonic dimension of wellbeing is perhaps not as relevant for people in Cognitive Stimulation Therapy. This finding would also suggest that session activities that foster a sense of greater autonomy and empowerment might be areas of consideration in developing the future direction of Cognitive Stimulation Therapy groups.

Finally, we investigated gender differences in relation to overall improvements in mental wellbeing. Similar to previous findings (Woods et al., 2006), women displayed a slightly greater overall improvement in their mental wellbeing following Cognitive Stimulation Therapy than men. However, unlike the results of Woods et al. (2006), this gender difference was not found to be significant. This may be due to the more even distribution of gender in our sample than that used in previous studies.

Limitations

The original 14-item survey Warwick-Edinburgh Mental Well-Being Scale was rejected due to the hypothesis that persons with dementia may find the full-scale difficult to complete (Deary, Watson, Booth, & Gale, 2013). The seven-item Short Warwick-Edinburgh Mental Well-Being Scale was chosen due to its greater robustness and appropriateness for our patient group; however, it has its own limitations. The Short Warwick-Edinburgh Mental-Well-Being Scale is a self-reporting survey which leaves it open to inconsistencies due to individual differences and different cognitive abilities. As a survey construct, it consists of several interrelating tasks (Schwarz, 2007) such as reading and interpreting items; storing this information in working memory; searching for an answer and converting this into a standard answer such as a numerical scale (Deary et al., 2013). A person with dementia may have difficulty sustaining attention (Ballard et al., 2001) and could be vulnerable to cognitive overload (Bäckman et al., 2004). Although the Short Warwick-Edinburgh Mental Well-Being Scale is shorter and therefore reduces the possibility of these effects, it has not been ‘normed’ for people with dementia and is only normed up to the age of 74, a full four years younger than the mean age of this study which was 78.

The Short Warwick-Edinburgh Mental Well-Being Scale is limited in its ability to capture the richness of wellbeing and happiness. It has been suggested that frequent monitoring of ‘in the moment’ experiences represents a better insight into mental wellbeing than ‘snapshot’ measurements of the pre- and post-evaluation used in this study (Dolan, Layard, & Metcalfe, 2011). It could well be that external influences such as a good final session or other life events influenced the final scores or whether the group setting helped create bias.

Cognitive Stimulation Therapy has a recommended protocol of 14 sessions each lasting 45 minutes. Within our service, we modified this protocol by offering a shorter course of sessions (10 sessions of 90 minutes each). Consequently, the generalisability of these results should be cautiously interpreted within the recommended treatment protocol.

Implications for future research

This paper has looked at a relatively short-term intervention and the immediate effect on a person’s wellbeing; further, longitudinal research looking at the continuing effects on mental wellbeing to map changes would indicate the longevity of the observed improvement on the Short Warwick-Edinburgh Mental-Well-Being Scale. In addition, research using a control group would be desirable to ascertain if the findings of this evaluation are as a result of Cognitive Stimulation Therapy or due to other variables (e.g. existing support systems).

Although mental wellbeing was examined in this paper using a quantitative methodology, a qualitative research approach could also further our understanding of the subjective and individual nature of this construct.

Validation of the Short Warwick-Edinburgh Mental Well-Being Scale is desirable for people with dementia. Currently, there are no measures that directly examine mental wellbeing for this cohort. This is somewhat surprising since mastery, confidence and autonomy in the face of cognitive deficits is a relevant area of interest in supporting people with dementia.

Furthermore, the results showed that people with dementia lacked confidence in their decision-making processes. Therefore, clinicians could aim to maximise the content of future Cognitive Stimulation Therapy sessions by including activities that allow people to make their own choices and gain confidence in their decision-making processes.

Conclusion

The results of this preliminary service evaluation are encouraging and suggest that Cognitive Stimulation Therapy may offer additional benefits such as improving a person’s mental wellbeing through fostering positive perceptions of their future. It may also offer protection against the deleterious effects of receiving a diagnosis of dementia. These results suggest that the scope of Cognitive Stimulation Therapy could be broadened to maintain a person’s mental wellbeing, personhood and optimism in the face of cognitive decline.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Catherine Allward, Humber (NHS) Foundation Trust, UK, is an assistant clinical psychologists working within the clinical psychology team at the Hull Memory Clinic. Catherine provides Cognitive Stimulation Therapy at the clinic under supervision of corresponding author Dr Chris Rewston.

Rosie Dunn, Humber (NHS) Foundation Trust, UK, is an assistant clinical psychologists working within the clinical psychology team at the Hull Memory Clinic. Rosie also holds an Assistant Research post at the University of Hull. Rosie provides Cognitive Stimulation Therapy under supervision of corresponding author Dr Chris Rewston.

Gemma Forshaw, Humber (NHS) Foundation Trust, UK, was an assistant clinical psychologists working within the Clinical Psychology team at the Hull Memory Clinic. She provided Cognitive Stimulation Therapy under supervision of corresponding author Dr Chris Rewston. Gemma has since gone on to undertake a Doctorate training program in Clinical Psychology.

Chris Rewston, Humber (NHS) Foundation Trust, UK, is a clinical psychologist and team leader at the Hull Memory Clinic. He qualified as a Clinical Psychologist in 2005 and has since worked predominately with Older People. He has previously published research into Anxiety and Depression in later life.

Nicola Wass, Humber (NHS) Foundation Trust, UK, was an assistant clinical psychologists working within the clinical psychology team at the Hull Memory Clinic. She provided Cognitive Stimulation Therapy under supervision of corresponding author Dr Chris Rewston. Nicola has since gone on to undertake a Doctorate training program in Clinical Psychology.

References

Bäckman

Wahlin

Å.

Small

B. J.

Herlitz

Winblad

Fratiglioni

(2004). Cognitive functioning in aging and dementia: The Kungsholmen Project. Aging, Neuropsychology, and Cognition, 11(2–3), 212–244. DOI:10.1080/13825580490511099.

Ballard

O’Brien

Gray

Cormack

Ayre

Rowan

Thompson

, … Tovee

(2001). Attention and fluctuating attention in patients with dementia with Lewy bodies and Alzheimer disease. Archives of Neurology, 58(6), 977–982. DOI:10.1001/archneur.58.6.977.

Deary

I. J.

Watson

Booth

Gale

C. R.

(2013). Does cognitive ability influence responses to the Warwick-Edinburgh Mental Well-Being Scale? Psychological Assessment, 25(2), 313–318. DOI:10.1037/a0030834.

Dolan

Layard

Metcalfe

(2011). Measuring subjective wellbeing for public policy: Recommendations on measures. Special Paper No. 23, Centre for Economic Performance. Retrieved from http://cep.lse.ac.uk/pubs/download/special/cepsp23.pdf

Emerson

(1985). Evaluating the impact of deinstitutionalization on the lives in mentally retarded people. American Journal of Mental Deficiency, 90(3), 277–288.

Felce

Perry

(1995). Quality of life: Its definition and measurement. Research in Developmental Disabilities, 16(1), 51–74. DOI:10.1016/0891-4222(94)00028-8.

Gallagher-Thompson

Thompson

L. W.

Rider

K. L.

(2004). California Older Peoples Pleasurable Events Schedule. Retrieved from http://oafc.standford.edu/coppes_files/coppes_measure_scoring.pdf

Naglie

(2007). Quality of life in dementia. The Canadian Journal of Neurological Sciences, 34(Suppl. 1), S57–S, 61. DOI:10.1017/S0317167100005588.

National Institute for Health and Care Excellence. (2011). NICE clinical guideline CG42: Dementia: Supporting people with dementia and their carers in health and social care. Retrieved from http://publications.nice.org.uk/dementia-cg42

10.

Olazaran

Reisberg

Clare

Cruz

Pena-Casanova

Del Ser

Woods

, … Muniz

(2010). Nonpharmacological therapies in Alzheimer’s disease: A systematic review of efficacy. Dementia and Geriatric Cognitive Disorders, 30(2), 161–178. DOI:10.1159/000316119.

11.

Salthouse

T. A.

(2006). Mental exercise and mental aging: Evaluating the validity of the “Use It or Lose It” hypothesis. Perspectives on Psychological Science, 1(1), 68–87. DOI:10.1111/j.1745-6916.2006.00005.x.

12.

Schalock

R. L.

(2000). Three decades of quality of life. Focus on Autism and Other Developmental Disabilities, 15(2), 116–127. DOI:10.1177/108835760001500207.

13.

Schwarz

(2007). Cognitive aspects of survey methodology. Applied Cognitive Psychology, 21(2), 277–287. DOI:10.1002/acp.1340.

14.

Spector

Gardner

Orrell

(2011). The impact of Cognitive Stimulation Therapy groups on people with dementia: Views from participants, their carers and group facilitators. Aging & Mental Health, 15(8), 945–949. DOI:10.1080/13607863.2011.586622.

15.

Spector

Thorgrimsen

Woods

Royan

Davies

Butterworth

Orrell

(2003). Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: Randomised controlled trial. The British Journal of Psychiatry, 183(3), 248–254. DOI:10.1192/bjp.183.3.248.

16.

Stewart-Brown

Tennant

Platt

Parkinson

Weich

(2009). Internal construct validity of the Warwick-Edinburgh Mental Well-being Scale (WEMWBS): A Rasch analysis using data from the Scottish Health Education Population Survey. Health and Quality of Life Outcomes, 7, 15. DOI:10.1186/1477-7525-7-15.

17.

Tennant

Hiller

Fishwick

Platt

Joseph

Weich

Parkinson

, … Stewart-Brown

(2007). The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): Development and UK validation. Health and Quality of Life Outcomes, 5, 63. DOI:10.1186/1477-7525-5-63.

18.

Whitehouse

P. J.

Rabins

P. V.

(1992). Quality of life and dementia. Alzheimer Disease and Associated Disorders, 6(3), 135–137.

19.

Wilson

Haddlesey

Johal

(2013). The impact of Cognitive Stimulation Therapy on perceptions of pleasure and enjoyable activity: A service evaluation. Faculty for the Psychology of Older People Newsletter, 124. Retrieved from http://www.psige.org/info/newsletter+back+issues

20.

Woods

Thorgrimsen

Spector

Royan

Orrell

(2006). Improved quality of life and cognitive stimulation therapy in dementia. Aging & Mental Health, 10(3), 219–226. DOI:10.1080/13607860500431652.