Delivery of Cognitive Stimulation Therapy for people with dementia in an inpatient setting (innovative practice)

Study design

The work undertaken was categorised as a service evaluation and consequently was exempt from ethical review according to the University Hospitals guidance. The purpose of the service evaluation was to gauge the level of attendance and feedback on Cognitive Stimulation Therapy as part of the patient’s usual care in an inpatient setting. No randomisation was required for the service evaluation as the focus was on service delivery and the current standard of care (National Research Ethics Service, 2009).

People voluntarily agreed to attend Cognitive Stimulation Therapy sessions as part of their usual care and no personal data was collected. In addition, the optional feedback gathered was non-identifiable. The patient’s willingness to attend groups and the voluntary nature of the feedback form was considered an indication of patient consent.

The sessions were delivered on two wards, with the first ward specialising in older people’s mental health, and accepting patients with dementia and suspected delirium. The ward received 92 admissions with an average length of patient stay of 11 days over the timeframe of the sessions delivered. The second ward specialises in inpatient rehabilitation, admitting patients requiring additional therapy input. This ward accepted 85 admissions with an average length of patient stay of 19 days.

On each ward, group attendees were initially identified through discussion between the occupational therapist and the nursing staff, mental health nurses, or the activity co-ordinators. Patients who participated in the groups were required to: (1) have a diagnosis of dementia and/or delirium, (2) verbally communicate well and (3) be physically well enough to get out of bed. Patients who met these criteria were invited to attend the session by the occupational therapist who led the group. The number of sessions attended per person and patient and staff feedback forms were gathered to evaluate the sessions delivered.

Program overview

The Cognitive Stimulation Therapy programme was delivered twice weekly on an ongoing basis by two occupational therapists on one ward, and once weekly by an occupational therapist and an activity co-ordinator on another ward. The sessions were evaluated over a month long period and the frequency of the sessions was determined in part by the working pattern of the part-time occupational therapist. Each session had a different theme, e.g. ‘Using money’, ‘Being creative’ and ‘Faces/scenes’ and each session was graded to be less or more demanding on an individual’s memory and cognition. The sessions were delivered for an hour between breakfast and lunch. Attendees were then encouraged by staff members to remain in the day room for their meals, as shared eating has been shown to be beneficial for nutritional intake for inpatients (Wright, Hickson, & Frost, 2006), and the delivery of the Cognitive Stimulation Therapy sessions provided an opportunity to encourage this amongst the group members.

Evaluation of programme

To evaluate the delivery of the Cognitive Stimulation Therapy programme, patient feedback forms were disseminated to each group attendee after each session over the month timeframe. Each question was on a 3-point Likert scale from agree, neither agree nor disagree, to disagree.

Attendance

Over a month timeframe one ward delivered eight sessions and ranged between five and seven patients across the sessions. The other ward delivered four sessions once weekly and ranged between four and six patients over the four sessions (Table 1).

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Table 1.

Number of sessions delivered and number range of attendees.

CST group	Facilitators	Number of sessions delivered	Range of attendees per session
Ward one	Two occupational therapists	8	5–7
Ward two	Occupational therapist and activity co-ordinator	4	4–6

Feedback

Not all attendees agreed to complete a feedback form, and the following reasons were given; the person had forgotten what the group was about, the person had already completed a form in a previous session, or the person left the group before it had finished and were subsequently busy with doctors or family members and could not be disturbed. In total, 66 feedback forms were distributed and of these 51 (77%) of feedback forms were fully completed, three (5%) were partially completed, and 12 (18%) were not completed.

From the 51 feedback forms returned, the majority of respondents agreed the group was enjoyable (92%), friendly (94%), interesting (86%), made them think (78%), were able to join in (88%), and would recommend the group to a friend or family member (86%). See Table 2 for further details.

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Table 2.

Feedback from attendees on attending the sessions.

Question	Agree (n %)	Neither agree nor disagree (n %)	Disagree (n %)	Total (n %)
The group was enjoyable	47 (92)	3 (6)	1 (2)	51 (100)
The group was friendly	48 (94)	3 (6)	0 (0)	51 (100)
I was able to join in with the group	45 (88)	2 (4)	4 (8)	51 (100)
The group was interesting	44 (86)	6 (12)	1 (2)	51 (100)
The group made me think	38 (78)	7 (14)	4 (8)	49 (96)
I would recommend the group to friends/family	41 (86)	5 (10)	2 (4)	48 (94)

Informal feedback was gathered, in the form of ‘any further comments’ at the end of the feedback form. Positive comments included ‘(it) gives you a lot of hope and understanding’, ‘that’s cheered me up’, ‘it was a way of meeting other patients, which was good’, and ‘it was very good, it’s certainly better than lying in bed’. There were also less positive comments collected that included, ‘(it was) nothing special but it’s enough’ and ‘it went on too long’. The largely positive feedback aligns with Cognitive Stimulation Therapy key principles (Aguirre et al., 2013), that includes principles such as fun, mental stimulation, and being person-centred.

From a clinical perspective, ward staff noticed a change in the behaviour of some of the patients. For example, one nursing staff could see a more positive side to a patient who had previously been verbally aggressive to staff, ‘it was so good. I’m really shocked. He was nothing like that before’. The occupational therapists observed that another patient, who prior to the group was preoccupied by her cannula and line delivering fluids (pulling and plucking at it) became more settled and focussed, and started making meaningful contributions in the group. The sessions also appeared to encourage improved communication of group members. For example, one patient started out withdrawn and uncommunicative in their first session and demonstrated limited engagement in the task by providing one word answers. There was however, a change in the subsequent session as the patient expressed interest through facial expressions and by using short sentences. Another patient gave mostly negative feedback after her first session but chose to attend again, gradually providing more positive feedback at each subsequent session. This may demonstrate that familiarity with the group facilitators and group structure led to a greater enjoyment and satisfaction when attending the sessions. The group facilitators paid attention to this, due to the changing members of the group and group size (Table 1), as it required careful planning to provide spontaneity in the delivery of the sessions.

There is an evidence base to support the delivery of Cognitive Stimulation Therapy for people with mild to moderate dementia. There is however, less known about the practical implications of delivering Cognitive Stimulation Therapy in an inpatient setting. A limitation of this reflection is the lack of quantitative outcome measures collected. The programme however, could not be delivered in a prescriptive manner and it was impossible to determine the duration of attendance of group members, so outcome measures were deemed neither feasible nor worthwhile.

The original Cognitive Stimulation Therapy programme was designed as a closed group format, however in an inpatient setting this was not possible and so it was held as an open session that could be attended by anyone who met the inclusion criteria. This led to variations in group attendees and group size on a daily basis. This is something that has not been evaluated in relation to Cognitive Stimulation Therapy before and should be considered in future work.

Although the initial focus was on the delivery of the Cognitive Stimulation Therapy programme in an inpatient ward setting it quickly apparent that there are additional benefits to the running of sessions which included implicit physical rehabilitation, re-orientation, socialisation, and flexibility in the delivery of the Cognitive Stimulation Therapy programme.

Low mobility has been identified as leading to adverse effects for patients (Brown, Redden, Flood, & Allman, 2009). However, to attend the group the patient was required to get out of bed, clothed, and walk to the end of the bay or the day room, or transfer into a wheelchair, so this involved both transfers and mobility. This inadvertently created an opportunity for physical benefits, as for people to socially participate in the Cognitive Stimulation Therapy group they were required to be mobile.

On an acute hospital ward the duration of the programme is impractical to deliver and consistency of group members is not possible, as patients are discharged within days rather than weeks. In addition, group members did not attend every session offered during their admission. Reasons for refusal included a poor night’s sleep the night before, not wishing to miss visitors, becoming more unwell, and feeling unsociable. These factors impacted on number of sessions attended, with individual attendance ranging from one to six, with most people attending only one session. Regardless of number of sessions attended, there is still a need for meaningful, stimulating activity for patients with dementia where possible.

During the session, there is implicit re-orientation of the person to the here and now. This provided an opportunity to re-orientate the person to the ward setting and the time and day. For people with dementia, disorientation is common in an inpatient setting, and there is evidence base to support the delivery of reality orientation (Spector, Orrell, Davies, & Woods, 2000), so there is a benefit in completing this activity. In addition, lunch was provided after the delivery of each session, and so this provided another opportunity for implicit orientation to the time of day.

Due to the changing population in the groups, some of the principles of Cognitive Stimulation Therapy groups had to be adapted. For example, rather than attendees nominating a group name, ‘Active minds’ was given as the group name. This provided continuity and consistency across sessions, allowing adherence to one of the Cognitive Stimulation Therapy key principles. Continuity and consistency supports memory and learning, and this was also demonstrated by running the group in the same day room, at the same time, and following the session structure as outlined in the manual (Spector, Thorgrimsen, Woods, & Orrell, 2006). In line with the formalised programme the group began with the group name and song, and for those people who attended more than one session this format became familiar and people requested the same song to be sung, and could anticipate this in the introduction to the session.

Another key principle of Cognitive Stimulation Therapy is strengthening relationships. To adhere to this principle the sessions were planned to encourage interactions between the group by presenting debate topics and facilitating joint discussion. Feedback from the questionnaire supported this key principle as people felt that groups were ‘friendly’ and that they were ‘able to join in’. For a group of patients who are at risk of feeling isolated, socialisation through the Cognitive Stimulation Therapy groups appeared to be particularly beneficial.

The group structure was based on the manual and on the first ward, followed the structure provided therein. On the second ward, some sessions were not feasible as the ward did not have the resources required, e.g. music for the Sound session and resources for the Being Creative session. In addition, some sessions were adapted by using laminated images rather than actual object to manage issues such as infection control. This is a practical limitation that should be taken in to account for future Cognitive Stimulation Therapy work in an inpatient setting.