Cognitive stimulation to improve cognitive functioning in
people with dementia (Review)
Woods B, Aguirre E, Spector AE, Orrell M
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2012, Issue 2
http://www.thecochranelibrary.com
Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Figure 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Figure 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Figure 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
21DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
24AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 1
Cognition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Analysis 1.2. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 2 MMSE. 55
Analysis 1.3. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 3 ADAS-
Cog. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Analysis 1.4. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 4 Other
cognitive measure: Information/Orientation. . . . . . . . . . . . . . . . . . . . . . . . 57
Analysis 1.5. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 5
Comunication and social interaction. . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Analysis 1.6. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 6 Well-being
& Quality of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Analysis 1.7. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 7 Mood: Self-
reported. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Analysis 1.8. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 8 Mood:
Staff-reported. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Analysis 1.9. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 9 ADL
scales. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Analysis 1.10. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 10
Behaviour, general. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
iCognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.11. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 11
Behaviour, problem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis 1.12. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment, Outcome 12 Caregiver
outcome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Analysis 2.1. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 1 Cognition. 66
Analysis 2.2. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 2 Well-being &
Quality of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Analysis 2.3. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 3 Behaviour,
general. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Analysis 2.4. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 4 Behaviour,
problem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Analysis 2.5. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 5 Communication
and social interaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
70APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
76HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
76CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
77DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
77SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
77NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
77INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiCognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Cognitive stimulation to improve cognitive functioning inpeople with dementia
Bob Woods1 , Elisa Aguirre2, Aimee E Spector3, Martin Orrell4
1Dementia Services Development Centre Wales, Bangor University, Bangor, UK. 2University College London, London, UK. 3Research
Department of Clinical, Educational and Health Psychology, University College, London, London, UK. 4Research Department of
Mental Health Sciences, University College London, London, UK
Contact address: Bob Woods, Dementia Services Development Centre Wales, Bangor University, 45 College Road, Bangor, Gwynedd,
LL57 2DG, UK. [email protected].
Editorial group: Cochrane Dementia and Cognitive Improvement Group.
Publication status and date: New, published in Issue 2, 2012.
Review content assessed as up-to-date: 6 December 2011.
Citation: Woods B, Aguirre E, Spector AE, Orrell M. Cognitive stimulation to improve cognitive functioning in people with dementia.
Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD005562. DOI: 10.1002/14651858.CD005562.pub2.
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Cognitive stimulation is an intervention for people with dementia which offers a range of enjoyable activities providing general
stimulation for thinking, concentration and memory usually in a social setting, such as a small group. Its roots can be traced back to
Reality Orientation (RO), which was developed in the late 1950s as a response to confusion and disorientation in older patients in
hospital units in the USA. RO emphasised the engagement of nursing assistants in a hopeful, therapeutic process but became associated
with a rigid, confrontational approach to people with dementia, leading to its use becoming less and less common.
Cognitive stimulation is often discussed in normal ageing as well as in dementia. This reflects a general view that lack of cognitive
activity hastens cognitive decline. With people with dementia, cognitive stimulation attempts to make use of the positive aspects of
RO whilst ensuring that the stimulation is implemented in a sensitive, respectful and person-centred manner.
There is often little consistency in the application and availability of psychological therapies in dementia services, so a systematic
review of the available evidence regarding cognitive stimulation is important in order to identify its effectiveness and to place practice
recommendations on a sound evidence base.
Objectives
To evaluate the effectiveness and impact of cognitive stimulation interventions aimed at improving cognition for people with dementia,
including any negative effects.
Search methods
The trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group Specialized Register, called ALOIS
(updated 6 December 2011). The search termsused were: cognitive stimulation, reality orientation, memory therapy, memory groups,
memory support, memory stimulation, global stimulation, cognitive psychostimulation. Supplementary searches were performed in a
number of major healthcare databases and trial registers to ensure that the search was up to date and comprehensive.
Selection criteria
All randomised controlled trials (RCTs) of cognitive stimulation for dementia which incorporated a measure of cognitive change were
included.
1Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data collection and analysis
Data were extracted independently by two review authors using a previously tested data extraction form. Study authors were contacted
for data not provided in the papers. Two review authors conducted independent assessments of the risk of bias in included studies.
Main results
Fifteen RCTs were included in the review. Six of these had been included in the previous review of RO. The studies included participants
from a variety of settings, interventions that were of varying duration and intensity, and were from several different countries. The
quality of the studies was generally low by current standards but most had taken steps to ensure assessors were blind to treatment
allocation. Data were entered in the meta-analyses for 718 participants (407 receiving cognitive stimulation, 311 in control groups). The
primary analysis was on changes that were evident immediately at the end of the treatment period. A few studies provided data allowing
evaluation of whether any effects were subsequently maintained. A clear, consistent benefit on cognitive function was associated with
cognitive stimulation (standardised mean difference (SMD) 0.41, 95% CI 0.25 to 0.57). This remained evident at follow-up one to
three months after the end of treatment. In secondary analyses with smaller total sample sizes, benefits were also noted on self-reported
quality of life and well-being (standardised mean difference: 0.38 [95% CI: 0.11, 0.65]); and on staff ratings of communication and
social interaction (SMD 0.44, 95% CI 0.17 to 0.71). No differences in relation to mood (self-report or staff-rated), activities of daily
living, general behavioural function or problem behaviour were noted. In the few studies reporting family caregiver outcomes, no
differences were noted. Importantly, there was no indication of increased strain on family caregivers in the one study where they were
trained to deliver the intervention.
Authors’ conclusions
There was consistent evidence from multiple trials that cognitive stimulation programmes benefit cognition in people with mild to
moderate dementia over and above any medication effects. However, the trials were of variable quality with small sample sizes and
only limited details of the randomisation method were apparent in a number of the trials. Other outcomes need more exploration but
improvements in self-reported quality of life and well-being were promising. Further research should look into the potential benefits
of longer term cognitive stimulation programmes and their clinical significance.
P L A I N L A N G U A G E S U M M A R Y
Can cognitive stimulation benefit people with dementia?
People with dementia and their caregivers are often advised that ’mental exercise’ may be helpful in slowing down the decline in memory
and thinking experienced by many people with dementia. This review examined the evidence for one form of mental exercise, described
as cognitive stimulation. This involves a wide range of activities that aim to stimulate thinking and memory generally, including
discussion of past and present events and topics of interest, word games, puzzles, music and practical activities such as baking or indoor
gardening. Typically this is carried out by trained staff with a small group of four or five people with dementia for around 45 minutes
at least twice a week. Family caregivers have also been trained to provide cognitive stimulation to their relative on a one-to-one basis.
This review included 15 trials with a total of 718 participants. The findings suggested that cognitive stimulation has a beneficial effect
on the memory and thinking test scores of people with dementia. Although based on a smaller number of studies, there was evidence
that the people with dementia who took part reported improved quality of life. They were reported to communicate and interact better
than previously. No evidence was found of improvements in the mood of participants or their ability to care for themselves or function
independently, and there was no reduction in behaviour found difficult by staff or caregivers. Family caregivers, including those who
were trained to deliver the intervention, did not report increased levels of strain or burden.
The trials included people in the mild to moderate stages of dementia and the intervention does not appear to be appropriate for people
with severe dementia. More research is needed to find out how long the effects of cognitive stimulation last and for how long it is
beneficial to continue the stimulation. Involving family caregivers in the delivery of cognitive stimulation is an interesting development
and merits further evaluation.
2Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
B A C K G R O U N D
Interventions with a cognitive focus have long been used in de-
mentia care. They have been developed in parallel with approaches
emphasising the stimulation of the senses (Woods 1977). Reality
Orientation (RO) (Taulbee 1966) was developed in the late 1950s
as a response to confusion and disorientation in older patients in
hospital units in the USA, and was the prototype of the cognitive
stimulation approach. Classes were held for 30 minutes once or
twice per day. Basic personal and current information was pre-
sented to the patient and a variety of materials used, such as in-
dividual calendars, word-letter games, building blocks and large-
piece puzzles. A Reality Orientation board would be used in each
session and would list the name of the unit and its location, the
day, date, weather, current events etc. The approach emphasised
the engagement of nursing assistants in a hopeful, therapeutic pro-
cess.
The first controlled evaluation of RO was reported in the UK by
Brook et al (Brook 1975). They found positive benefits on ratings
of intellectual and social functioning in patients attending RO
group sessions for 30 minutes per day, five days per week for four
months compared with a control group who visited a special RO
room daily but were not given any encouragement to engage with
the materials or each other. A spate of controlled studies followed
(Holden 1995), with outcome measures typically including assess-
ments of orientation, other aspects of cognitive functioning and
level of independent functioning. A Cochrane review specifically
examining Reality Orientation (Spector 2000a; Spector 2000b)
concluded that there was some evidence that RO had benefits for
people with dementia on both cognition and behaviour. How-
ever, outside of a few countries (notably Italy), RO has been little
practised or researched since 1990 and has attracted some crit-
icism (Burton 1982; Dietch 1989; Powell-Proctor 1982), espe-
cially for being applied in a mechanical, inflexible, insensitive and
confrontational manner. Doubts were also raised about the clin-
ical significance of any improvements; the person with dementia
might now know what day of the week it was but would this have
any meaningful impact on the person’s life? Such was the concern
regarding the insensitive use of RO and other cognitive approaches
that one influential set of guidelines on the management of de-
mentia (APA 1997) cautioned against their use with the possibility
of a negative impact on the person’s well-being that outweighed
any small cognitive improvements.
In addition to the ’classroom’ element of RO, from the early days
’24 hour RO’ was also advocated. This involves staff taking every
opportunity to provide current information to the person, outside
of the formal setting of the RO group, as well as using environ-
mental features such as sign-posting and orientation boards to as-
sist orientation. There have been some positive evaluations of the
effects of training and sign-posting on orientation around a care
facility (for example Hanley 1981; McGilton 2003) but the effects
of 24 hour RO per se have been more difficult to evaluate. This
is not least of all because of the difficulty in monitoring its imple-
mentation, with informal interactions being much more difficult
to document than a formal group meeting. Williams 1987 reports
using a modified form of 24 hour RO where staff were trained to
respond appropriately to residents’ requests for information, and
found that 90% of staff responses to residents’ requests complied
with the treatment protocol. This study reported improvements
in cognition, independent functioning and orientation, compared
with a control group on a separate ward, when this form of 24
hour RO was implemented.
Alongside the RO literature, in recent years there has been increas-
ing discussion of ’cognitive stimulation’. In part this reflects a gen-
eral view that lack of cognitive activity hastens cognitive decline,
in normal ageing as well as in dementia (Breuil 1994; Small 2002),
and in part it is an attempt to make use of the positive aspects of
RO whilst ensuring that it is implemented in a properly sensitive
and respectful manner (Spector 2001; Woods 2002). There has
also been growing interest in the application of various forms of
cognitive training and in teaching individual people with demen-
tia to use memory aids and strategies to assist with their particular
difficulties that have been identified with the person. A Cochrane
review of cognitive training and cognitive rehabilitation in early
stage dementia has been completed (Clare 2003) and it is impor-
tant to ensure that clear definitions are used to avoid confusion
between the various cognition-based approaches, as in the past
’training’, ’stimulation’ and ’rehabilitation’ have been used almost
interchangeably.
Clare and Woods (Clare 2004) proposed the following definitions.
Cognitive stimulation is engagement in a range of activities and
discussions (usually in a group) aimed at general enhancement of
cognitive and social functioning.
Cognitive training is guided practice on a set of standard tasks
designed to reflect particular cognitive functions; a range of diffi-
culty levels may be available within the standard set of tasks to suit
the individual’s level of ability. It may be offered in individual or
group sessions, with pencil and paper or computerised exercises.
Cognitive rehabilitation is an individualised approach where per-
sonally relevant goals are identified and the therapist works with
the person and his or her family to devise strategies to address
these. The emphasis is on improving performance in everyday life
rather than on cognitive tests, building on the person’s strengths
and developing ways of compensating for impairments
Using these definitions, this review included studies on RO group
sessions but not on 24 hour RO or direct training in spatial orien-
tation. The primary outcomes examined will be in relation to the
person’s cognitive functioning. It is considered that this is the min-
imum expectation of a general approach with this focus. However,
3Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
given the concerns discussed above of a possible negative effect,
measures of quality of life, mood and well-being are highly per-
tinent secondary outcome measures. The effects on the person’s
general level of function in everyday life also need to be considered
in evaluating the meaning of any changes observed for the individ-
ual and his or her supporters. The impact on family caregivers and
careworkers is also important to consider as they are key partners
in the process of care.
O B J E C T I V E S
• To evaluate the effectiveness and impact of cognitive
stimulation interventions aimed at improving cognition for
people with dementia, including any negative effects.
• To indicate the nature and quality of the evidence available
on this topic.
• To assist in establishing the appropriateness of offering
cognitive stimulation interventions to people with dementia and
identifying the factors associated with their efficacy.
M E T H O D S
Criteria for considering studies for this review
Types of studies
This review focused on randomised controlled trials (RCTs) for
which adequate information was provided or could be obtained
from the researchers. The studies included must have been pub-
lished, written in English and presented in a peer-reviewed journal
article.
Types of participants
• Participants with a diagnosis of dementia. The main
diagnostic categories that were included were Alzheimer’s disease,
vascular dementia or mixed Alzheimer’s and vascular dementia.
These diagnostic categories were considered together. Older
studies, included from the previous review of RO, used other
terms for this population but were included where the review
authors were satisfied that the included population would now
be described as having a dementia. Participants with mild
cognitive impairment, where the extent of cognitive impairment
or its effects on day-to-day function were insufficient to justify a
dementia diagnosis, were not included.
• Severity of dementia was indicated through group mean
scores, range of scores, or individual scores on a standardised
scale such as the Mini-Mental State Examination (MMSE)
(Folstein 1975) or Clinical Dementia Rating (CDR) (Hughes
1982). All levels of severity were included.
• Qualifying participants received the intervention in a range
of settings, including their own home, as outpatients and in day-
care and residential settings.
• No specific restrictions regarding age were applied.
• Data from family caregivers were included where this was
available and where the relationship between the caregiver and
the person with dementia was specified, including whether they
were co-resident.
• The number of participants receiving concurrent treatment
with acetylcholinesterase inhibitors was documented, where
possible.
Types of interventions
• Studies were considered for this review if they described a
cognitive stimulation intervention targeting cognitive and social
functioning. These interventions may also have been described as
RO groups, sessions or classes.
• The definition of cognitive stimulation as proposed by
Clare 2004 was adopted. This meant that some studies which
described their intervention as ’cognitive stimulation’ were
excluded. Interventions needed to offer exposure to generalised
cognitive activities rather than training in a specific modality.
• Interventions were typically conducted in a group to
enhance social functioning, or could involve family caregivers.
• Studies were included if a comparison was made to ’no
treatment’, ’standard treatment’ or placebo. Standard treatment
was understood to be the treatment that was normally provided
to patients with dementia in the study setting and could include
provision of medication, clinic consultations, contact with a
community mental health team, day care, or support from
voluntary organisations. Placebo conditions could consist, for
example, of an equivalent number of sessions in which general
support, but no structured intervention, was offered.
• The minimum duration of intervention for inclusion of a
study was one month. There were no restrictions on the number
of treatment sessions, although this was noted.
Types of outcome measures
• Outcomes were considered in relation to the impact of the
intervention on the person with dementia and on the primary
family caregiver. Studies could present data in both these
categories.
• Short term (immediately after the intervention) and
medium term (follow-up one month to one year after the
intervention finished) outcomes were considered.
• Outcomes for the person with dementia and the caregiver
were considered where these were assessed using scores on
standardised tests, rating scales and questionnaires.
4Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
• Rates of attrition and reasons for participants dropping out
from the study were noted.
Outcomes for the person with dementia
Outcome measures for the person with dementia sought to identify
whether changes were observed following the intervention. The
following variables were considered as outcome measures for the
person with dementia.
• Performance on at least one test of cognitive functioning
(including tests of memory and orientation).
• Self-reported, clinically-rated or carer-reported measures for
mood of the person with dementia.
• Self-reported or carer-reported quality of life or well-being
measures for the person with dementia.
• Observer or carer ratings of everyday functioning (activities
of daily living) of the person with dementia.
• Carer ratings of the participant’s behaviour.
• Clinician or carer ratings of neuropsychiatric symptoms or
behaviour problems of the person with dementia.
• Clinician or carer ratings of the social engagement of the
person with dementia.
’Carer’ in this context included care staff as well as family care-
givers.
Outcomes for the family caregiver
The outcomes for the family caregiver that were considered in-
cluded any of the following.
• Self-reported well-being, depression and anxiety.
• Self-reported burden, strain and coping.
• Satisfaction with the intervention.
Search methods for identification of studies
We searched ALOIS (
www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cog-
nitive Improvement Group Specialized Register, on 6 December
2011. The search terms used were: cognitive stimulation, reality
orientation, memory therapy, memory groups, memory support,
memory stimulation, global stimulation, cognitive psychostimu-
lation.
ALOIS is maintained by the Trials Search Co-ordinator of the
Cochrane Dementia and Cognitive Improvement Group and con-
tains studies in the areas of dementia prevention, dementia treat-
ment and cognitive enhancement in healthy populations. The
studies are identified from:
1. monthly searches of a number of major healthcare
databases: MEDLINE, EMBASE, CINAHL, PsycINFO and
LILACS;
2. monthly searches of a number of trial registers: meta
Register of Controlled Trials; Umin Japan Trial Register; WHO
portal (which covers ClinicalTrials.gov; ISRCTN; Chinese
Clinical Trials Register; German Clinical Trials Register; Iranian
Registry of Clinical Trials and the Netherlands National Trials
Register, plus others);
3. quarterly search of the Cochrane Central Register of
Controlled Trials (CENTRAL) (The Cochrane Library);4. six-monthly searches of a number of grey literature sources:
ISI Web of Knowledge Conference Proceedings; Index to
Theses; Australasian Digital Theses.
To view a list of all sources searched for ALOIS see About ALOIS
on the ALOIS website.
Details of the search strategies used for the retrieval of reports of
trials from the healthcare databases, CENTRAL and conference
proceedings can be viewed in the ‘methods used in reviews’ sec-
tion within the editorial information about the Dementia and
Cognitive Improvement Group (CDCIG).
Additional searches in each of the sources listed above, to cover
the timeframe from the last searches performed for the Specialized
Register to December 2011, were run to ensure that the search for
the review was as up to date as possible. The search strategies used
can be seen in Appendix 1.
A total of 804 references were retrieved from the December 2011
search. After de-duplication and a first assessment, authors were
left with 41 references to further assess for either inclusion, exclu-
sion or discarding.
Data collection and analysis
Searches were conducted as detailed above to identify all relevant
published studies. The date and time of each search, together with
details of the version of the database used, were recorded. Addi-
tional information was sought, as outlined above, and hard copies
of articles were obtained.
Quality assessment
RCTs were identified and the two review authors (BW and EA)
worked independently to determine which studies met the criteria
for inclusion. Trials that did not meet the criteria were excluded,
and reasons for exclusion were noted in the table ’Characteristics
of excluded studies’. Review authors’ selections of trials were com-
pared and the final list of included studies was reached by consen-
sus.
The selected RCTs were described in tabular form, permitting an
evaluation of their methodological quality. Studies were assessed
against a checklist of quality requirements using the Cochrane
approach (see risk of bias tables).
• Grade A, ’Low risk’: adequate concealment (randomisation;
concealed allocation).
5Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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• Grade B, ’Unclear risk’: “randomised”, but methods
uncertain.
• Grade C, ’High risk’: inadequate concealment of allocation
or no randomisation, or both.
Only trials with a grade A or B ranking were included in the re-
view. Again, the review authors worked independently to ascertain
which studies met the quality criteria, and consensus was reached
through discussion. Attempts were made to obtain additional in-
formation from the study authors when further data were needed.
Data extraction
Data from the RCTs selected for inclusion were extracted, recorded
and entered into RevMan. The summary statistics required for
each trial and each outcome for continuous data were the mean
change from baseline, the standard error of the mean change, and
the number of patients for each treatment group at each assess-
ment point. Where changes from baseline were not reported, the
review authors extracted the mean, standard deviation and the
number of patients for each treatment group at each time point,
if available. The review authors calculated the required summary
statistics from the baseline and post-treatment group means and
standard deviations, assuming in this case a zero correlation be-
tween the measurements at the baseline and follow-up time points.
This method overestimates the standard deviation of the change
from baseline but this conservative approach was chosen as it is
preferable in a meta-analysis. For binary data, the review authors
sought the numbers in each treatment group and the numbers
experiencing the outcome of interest. The baseline assessment was
defined as the latest available assessment prior to randomisation,
but no longer than two months prior.
For each outcome measure, data were sought on every patient
randomised. To allow an intention-to-treat analysis, the data were
sought irrespective of compliance and whether or not the patient
was subsequently deemed ineligible or otherwise excluded from
treatment or follow-up. If intention-to-treat data were not avail-
able in the publications, ’on-treatment’ data or the data of those
who completed the trial were sought and were indicated as such.
In studies where a cross-over design was used, only data from the
first treatment phase after randomisation were eligible for inclu-
sion.
As the outcomes measured in clinical trials of dementia and cog-
nitive impairment often arise from ordinal rating scales, where the
rating scales had a reasonably large number of categories (more
than 10) the data were treated as continuous outcomes arising
from a normal distribution.
Data analysis
The meta-analyses included the combination of data from trials
that may not use the same rating scale to assess an outcome. There-
fore, the measure of the treatment difference for any outcome used
was the weighted mean difference when the pooled trials used the
same rating scale or test and the standardised mean difference (the
absolute mean difference divided by the standard deviation) when
they used different rating scales or tests. The duration of the trials
may vary considerably. If the review authors considered the range
too great to combine all trials into one meta-analysis, they divided
it into smaller time periods and conducted a separate meta-analy-
sis for each period. Some trials may have contributed data to more
than one time period if multiple assessments were made.
The meta-analyses presented overall estimates of the treatment
difference from a fixed-effect model and a test for heterogeneity
was performed using a standard Chi2 statistic. Where there was
evidence of heterogeneity of the treatment effect between trials
then a random-effects model was utilised (which results in broader
confidence intervals than for those of a fixed-effect model).
The review authors discussed and reached consensus on the in-
terpretation of the statistical analyses, seeking specialist statistical
advice from CDCIG as required. The review authors discussed
and reached consensus on the presentation of the findings in the
background to the review.
R E S U L T S
Description of studies
See: Characteristics of included studies; Characteristics of
excluded studies; Characteristics of studies awaiting classification;
Characteristics of ongoing studies.
From the initial set of references identified by the updated sys-
tematic searches (since our last review, Spector 2000a), 53 po-
tentially relevant studies were identified. Of these, seven studies
met the inclusion criteria (Baldelli 2002; Bottino 2005; Chapman
2004; Onder 2005; Requena 2006; Spector 2001; Spector 2003)
and were included in this review. Our previous review (Spector
2000a) included eight studies in the meta-analysis, six of which
were included in this replacement review (Baines 1987; Baldelli
1993a; Breuil 1994; Ferrario 1991; Wallis 1983; Woods 1979).
For the two studies excluded at this stage, the data needed for the
current analyses were not available (Gerber 1991; Hanley 1981).
Full details of included studies and reasons for exclusion of ex-
cluded studies are presented in the tables ’Characteristics of in-
cluded studies’ and ’Characteristics of excluded studies’. The pre-
publication search in December 2011 identified 41 further stud-
ies for consideration. Two further studies (Buschert 2011; Coen
2011) met the inclusion criteria and have been added to the re-
view, with three further studies awaiting classification (Buettner
2011; Fernandez-Calvo 2010; Niu 2010).
Overall, 718 participants, 407 in the treatment groups and 311
in the control groups, were included in the analyses of the 15 in-
cluded studies. The included studies varied in many aspects: (1)
6Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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participant characteristics; (2) number and duration of cognitive
stimulation sessions; (3) activities which defined cognitive stim-
ulation; (4) the activity of the control group; and (5) outcome
measures. These factors will be considered in turn.
1) Participant characteristics
Diagnosis: eight of the nine new studies specified the diagnostic
criteria used. Coen 2011 simply described their participants as hav-
ing mild to moderate dementia; Spector 2001 and Spector 2003
used DSM-IV criteria, but did not break the participants down
by dementia subtype; Baldelli 2002 included similar numbers of
participants with “Degenerative senile dementia of the Alzheimer’s
type (SDAT)” (N = 46) and “vascular multi-infarct dementia”
(N = 41), although all had experienced at least one cerebrovascu-
lar accident resulting in motor deficits; Bottino 2005, Buschert
2011, Chapman 2004, Onder 2005 and Requena 2006 all speci-
fied a diagnosis of probable Alzheimer’s disease (AD) according to
NINCDS-ADRDA criteria linked with either ICD-10 or DSM-
IIIR criteria. In these studies, participants were on a stable dose
of an acetylcholinesterase inhibitor (ACHEI) (rivastigmine in the
Bottino 2005 study; donepezil in the remaining studies apart from
Buschert 2011 where a variety of medications including meman-
tine were being taken). Amongst the earlier studies, Breuil 1994
specified DSM-III criteria for dementia and Baldelli 1993a stated
that their participants were diagnosed with “Alzheimer’s (SDAT)
”. The four studies from 1991 and earlier specified more general
criteria using cognitive measures that indicated that dementia di-
agnoses were justifiable (Baines 1987; Ferrario 1991; Wallis 1983;
Woods 1979).
Ten of the 11 most recent studies provided mean baseline scores
on the Mini-Mental State Examination (MMSE), and the 11th
(Ferrario 1991) provided the MMSE score range for participants.
Coen 2011, Spector 2001 and Spector 2003 were the only studies
with a mean MMSE score in the moderate range (10 to 20), per-
haps reflecting the upper limit of 24 for participants to be included
in these studies. The mean scores (16.9, 13.1 and 14.4 respec-
tively) were several points lower than those in the eleven studies
reporting mean scores (mean average 19.7), and outside the range
of 18 to 25 specified by Ferrario 1991. However, those studies
where the mean score was in the mild range (> 20) may well have
included participants in the moderate or even the severe range, for
example the lowest score in the Breuil 1994 study was reported to
be 9. In general, however, it can be said that the studies included
in this review had targeted participants in the mild to moderate
range of cognitive impairment.
The average age of participants was over 70 years in all studies
(except Wallis 1983 where it was 69.8 years); in 6 studies it was
over 80 years. The average mean age across the 15 studies was
78.8 years, with the range of ages that were reported from 38 to
97 years. Over half the studies reported inclusion of participant(s)
aged 90 years and above.
Participants were resident in care homes, nursing homes or hospi-
tals, apart from six studies (Bottino 2005; Breuil 1994; Buschert
2011; Chapman 2004; Onder 2005; Requena 2006) where all the
participants were outpatients living in the community. The par-
ticipants included in the Spector 2001 and Spector 2003 studies
were recruited from both residential care homes and day centres,
with the former being in the majority.
2) Length, number and duration of sessions
The length of the intervention varied from four weeks (the min-
imum for inclusion in the review) to 24 months, with the stated
length of sessions varying from 30 minutes to 90 minutes. In
general, the sessions of longer duration were associated with the
lowest frequency (once a week). The median session length across
the studies was 45 minutes, and the median frequency was three
times a week, ranging from once to five times a week. The total
possible exposure to the intervention varied dramatically, from 10
to 12 hours (Baines 1987; Breuil 1994; Chapman 2004; Coen
2011; Spector 2001; Spector 2003) to 375 hours in the two-year
(Requena 2006) study. Across the 15 studies, the median exposure
time was 30 hours. Requena 2006 presented data from both the
12 month and 24 months time point in their study. As there was
less attrition at the 12 month time point, and this was more com-
parable (although still longer) in duration to the other studies, the
12 month data were used in combination with other studies in the
meta-analyses, with the 24 month data reported separately.
3) Activities during cognitive stimulation
The level of detail provided in the published papers regarding the
activities undertaken varied greatly. All studies used small group
sessions, typically with groups of five to seven participants, with
the exception of Onder 2005 where family caregivers were taught
to carry out cognitive stimulation with the person with dementia
on an individual basis. These individual sessions, led by family
caregivers, included current information, topics of general interest,
historical events and famous people, attention, memory and visuo-
spatial exercises and the use of clocks, calendars and notes.
Early studies described the use of an RO board and discus-
sion of current orientating information through newspapers, pho-
tographs, calendars and clocks etc., with materials selected to stim-
ulate all five senses (for example Baines 1987; Wallis 1983; Woods
1979). Breuil 1994 introduced a number of more specific cogni-
tive activities including drawing, associating words, object nam-
ing and categorising. Spector 2006 provided a detailed session by
session treatment manual for the approach used in their studies.
Activities in their sessions were designed with four themes: (1) the
senses, (2) remembering the past, (3) people and objects, and (4)
everyday practical issues. Activities included naming objects and
people, association of words, remembering the past, discussion of
7Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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hobbies, activities and current affairs, using money, knowing the
way around and orientation topics. This treatment manual was
also used by Coen 2011. Chapman 2004 reported topics includ-
ing current events, discussion of hobbies and activities, education
regarding Alzheimer’s disease, life story work, and links with daily
life with groups of six to seven participants. Bottino 2005 described
temporal and spatial orientation, discussion of interesting themes,
reminiscence activities, naming people, planning of daily activities
and use of calendars and clocks and other external memory aids.
Requena 2006 described, for groups of five people with dementia,
visual images being shown on a TV screen from a computer and
that reflected seven themes: orientation, bodily awareness, family
and society, caring for oneself, reminiscing, household activities,
animals, people and objects. These were accompanied by ques-
tions for discussion.
None of the included trials adopted 24 hour RO in addition to
group sessions, although Bottino 2005 described involving family
caregivers in encouraging the use of external memory aids at home,
Buschert 2011 described the use of exercises and tasks to be carried
out at home between sessions and Onder 2005 encouraged family
caregivers to informally engage in reality-based communication
with the person with dementia two or three times a day.
4) Control group(s) activities
In the earlier studies, alternative group activities were offered that
were of a social (Woods 1979) or diversional (Wallis 1983) na-
ture. Baines 1987 offered an alternative treatment, reminiscence
groups, but for the purposes of this review it was the no-treatment
group that was included in the analyses. ’Treatment as usual’ or
no treatment was the control condition in a number of studies
(Baldelli 1993a; Breuil 1994; Coen 2011; Ferrario 1991; Spector
2001; Spector 2003). In those studies where participants were also
taking ACHEIs, the control group were typically monitored in
relation to the medication (Chapman 2004; Bottino 2005; Onder
2005; Requena 2006). Requena 2006 reported that their control
participants watched TV whilst the cognitive stimulation groups
were in session. Baldelli 2002 engaged both the control and cog-
nitive stimulation participants in a physical therapy programme.
Buschert 2011 asked control participants to complete pencil and
paper tasks at home, encouraged by monthly group meetings.
5) Outcome measures
As a condition of inclusion, cognitive tests were used in all the
studies. Eleven studies used the MMSE (Folstein 1975) and eight
of the more recent studies also used the Alzheimer’s Disease As-
sessment Scale - Cognitive (ADAS-Cog) (Rosen 1984). Unfortu-
nately, only the 10 month follow-up data on these and other mea-
sures could be utilised from Chapman 2004 as it has not proved
possible to obtain their data at earlier time points in an extractable
form. Four studies used a self-report quality of life measure with
participants with dementia (Buschert 2011; Chapman 2004; Coen
2011; Spector 2003), but again the Chapman 2004 data was not
in a useable form. Five studies used a self-report depression mea-
sure (four making use of a version of the Geriatric Depression
Scale: Yesavage 1983), and four studies used a depression or anx-
iety scale completed from carer reports as well as from interviews
with the participants (such as the Cornell Scale for Depression in
Dementia: Alexopoulos 1988). A variety of scales have been used
to evaluate behaviour, with activities of daily living (ADL) scales
used in four studies, general behaviour ratings in seven studies
and problem behaviour scales used in three studies. Family care-
giver outcome measures were used in three studies (Bottino 2005;
Onder 2005; Spector 2001).
A full list of the outcome measures used in the included studies
can be found in the table Characteristics of included studies’.
Risk of bias in included studies
Details for each study are provided in the ’Characteristics of in-
cluded studies’ table.
Allocation
For a study to be included in this review, the review authors had
to be satisfied that random allocation to treatment conditions had
been used. To ascertain this, in several cases it was necessary to seek
further information from the study authors (for example Baldelli
1993a; Baldelli 2002; Ferrario 1991; Requena 2006). Remote or
computerised randomisation was only used in four of the most
recent studies (Bottino 2005; Chapman 2004; Buschert 2011).
Earlier studies described drawing names from a hat or a sealed
container, where it was possible to obtain details of the randomi-
sation procedure.
Blinding
Performance bias
With psychological interventions, unlike drug trials, it is impos-
sible to totally blind participants and staff to treatment. Partici-
pants will often be aware that they are being treated preferentially
and the staff involved may have different expectations of treat-
ment groups. There may also be ’contamination’ between groups
in terms of group sessions not being held in separate rooms and
staff bringing ideas from one group to another, so that control
participants receive elements of cognitive stimulation. The latter
effect would be reduced with clear therapeutic protocols, the ex-
istence of which was not clear in most study reports.
8Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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In relation to contamination, Wallis 1983 and Baines 1987 both
stated that the staff were unaware of the allocation of participants
to groups, as they were removed from the ward setting for treat-
ment, and several other studies described the groups being run in
a separate or specific room (for example Ferrario 1991; Spector
2001; Spector 2003; Woods 1979).
Detection bias
Most studies took steps to ensure that at least part of the assessment
of outcomes was carried out by assessors blind to treatment allo-
cation. Only three studies (Baldelli 1993a; Baldelli 2002; Ferrario
1991) did not report blinding of assessors. Of course, even inde-
pendent assessors may be given clues from participants during the
assessments, but this was not reported as an issue in the studies
reviewed here. Using independent assessors works well for evalu-
ating changes in cognition or self-reported mood, well-being and
quality of life. Ratings of day-to-day behaviour and function are
typically carried out by care staff, who may be more difficult to
keep blind to group allocation, unless the group sessions were car-
ried out in a separate location to which all participants were taken.
Incomplete outcome data
Only two studies described following an intention-to-treat analy-
sis plan (Chapman 2004; Spector 2003). In contrast, Breuil 1994
stated that “All those who for any reason did not attend all eval-
uation and training sessions were eliminated”, with five partici-
pants excluded on this basis (three from the cognitive stimulation
group).
All studies reported data on attrition. Given the nature of the con-
dition and the age of the participants, attrition in several stud-
ies was remarkably small, with zero attrition recorded in six stud-
ies (Baines 1987; Baldelli 1993a; Baldelli 2002; Bottino 2005;
Buschert 2011; Coen 2011), out of 180 participants. The largest
attrition rate was reported by Wallis 1983 where there was 39%
attrition in the group of participants with dementia. In this study
patients who attended less than 20% of the group sessions were
eliminated from the study. Requena 2006 reported 32% attrition
but this was over a two year period. The two largest studies had
rates of 19% (Onder 2005) and 17% (Spector 2003) over periods
of six months and two months respectively.
Other potential sources of bias
The absence of detailed treatment protocols raised queries regard-
ing the extent to which the cognitive stimulation was delivered
as intended (having noted that there may have been differences
in emphases between studies in any case). Several studies noted
that staff received training or supervision, or both, in running the
groups and, from an early study, Woods 1979 stated in a personal
communication that “A sample of sessions were tape-recorded and
rated to ensure compliance with the therapeutic protocol”. More
recently, Chapman 2004 described weekly meetings to ensure their
treatment programme was implemented as designed. Subgroups
were led by a licensed speech-language pathologist and three mas-
ter’s level speech-language pathology students; all underwent two
hour training before the groups started and weekly meetings were
held to ensure that the programme was implemented as designed.
Onder 2005 described how family caregivers were trained by a
multi-disciplinary team and given a manual and specific schedules
for each session. No records were made, however, of how often
caregivers did deliver the sessions, or how closely the manual was
followed.
Effects of interventions
For meta-analyses we used RevMan 5.1.
Cognition
(See Figure 1)
9Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 1. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome:
Cognition.
10Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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For the overall evaluation of the effects of cognitive stimulation
on cognitive function, all 14 RCTs which included useable data
immediately post-treatment were included, including a total of
658 people with dementia of whom 377 received cognitive stim-
ulation and 281 received no treatment or a placebo treatment. As
most studies included more than one measure of cognitive func-
tion, this analysis was conducted on the most extensive assessment
included. For seven studies this was the ADAS-Cog, and for two
each it was the MMSE and CAPE Information/Orientation scales.
The overall effect size, the standardised mean difference (SMD)
was 0.41 (95% CI 0.25 to 0.57). This was a statistically significant
finding (Z = 5.04, P < 0.00001). For the seven studies, including
434 participants, using the ADAS-Cog as an outcome measure
(Figure 2), the mean difference between the cognitive stimulation
and control groups was 2.27 points (95% CI 0.99 to 3.55), a
statistically significant difference (Z = 3.48, P < 0.0005). In to-
tal, 10 studies involving 600 participants used the MMSE (Figure
3). The overall mean difference was 1.74 points (95% CI 1.13
to 2.36). Again, this was a statistically significant difference (Z =
5.57, P < 0.00001). These analyses were strongly influenced by
two of the more recent studies, Spector 2003 and Onder 2005,
which were relatively large and had smaller confidence intervals
around their reported mean differences. Five of the older studies
involving 81 participants used other measures of information or
orientation (Figure 4); here the SMD was no smaller (SMD 0.45,
95% CI -0.01 to 0.90) and was just statistically significant despite
the much smaller numbers involved (Z = 1.93, P = 0.05).
Figure 2. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: ADAS-
Cog.
11Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 3. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: MMSE.
Figure 4. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: Other
cognitive measure: Information/Orientation.
12Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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The largest effect sizes were seen at the 12 month time point in the
Requena 2006 study (SMD 0.70 on ADAS-Cog) and the Baldelli
1993a study (SMD 0.99 on MMSE), both of which offered above
average durations of exposure to cognitive stimulation. However,
Breuil 1994, which offered only 10 hours exposure, also had an
above average effect size (0.63 on global cognitive score) and other
studies with longer exposure (for example Ferrario 1991) had be-
low average effect sizes. The 24 month data from Requena 2006
indicated that effect sizes appeared to be maintained through con-
tinued exposure (ADAS-Cog SMD 0.66: MD 11.94 points, 95%
CI -0.97 to 24.85; MMSE SMD 0.56: MD 5.99 points, 95% CI
-1.58 to 13.56). However, these effects require replication as the
confidence intervals were broad and crossed zero.
Communication and social interaction
(See Figure 5)
Figure 5. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment,
outcome: Comunication and social interaction.
Four studies, involving 223 participants, included staff ratings of
the person’s communication and social interaction (outside of the
cognitive stimulation group), three using the Holden Commu-
nication Scale. The overall effect size (SMD) was 0.44 (95% CI
0.17 to 0.71) with participants in the cognitive stimulation groups
showing a significant improvement in this area (Z = 3.15, P =
0.002). Spector 2003 was the most influential study in this anal-
ysis, although the effect was not reported as significant in the pri-
mary study report.
Well-being and quality of life
(See Figure 6)
13Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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Figure 6. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: QoL-
AD.
Four studies, involving 219 participants, included relevant self-
report measures. Baines 1987 used the Life Satisfaction Index and
Spector 2003, Buschert 2011 and Coen 2011 used the QoL-AD.
The meta-analysis indicated that cognitive stimulation was asso-
ciated with a significant benefit to well-being and quality of life
compared with no treatment (SMD 0.38, 95% CI 0.11 to 0.65)
(Z = 2.76, P = 0.006). The Spector 2003 findings were again a
major influence.
Mood
(See Figure 7; Figure 8)
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Figure 7. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome:
Geriatric Depression Scale (GDS-30)
Figure 8. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment,
outcome: Mood: Staff-reported.
15Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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Five studies, involving 201 participants, used a self-report measure
of mood (the Geriatric Depression Scale or the MADRS). Cog-
nitive stimulation was not associated with a clear improvement in
mood across these studies. The SMD was 0.22 (95% CI -0.09 to
0.53) (Z = 1.42, P = 0.16).
Staff ratings of mood and anxiety similarly did not show any bene-
fit from cognitive stimulation. Four studies, involving 239 partici-
pants, contributed to this analysis, two using the Cornell Scale for
Depression in Dementia, a third using a subscale of the MOSES
scale and the fourth the Rating of Anxiety in dementia. The SMD
was close to zero in this domain (SMD 0.05, 95% CI -0.21 to
0.31).
Behaviour
(See Figure 9; Figure 10; Figure 11)
Figure 9. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: ADL.
Figure 10. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome:
Behavior, Other.
16Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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Figure 11. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment,
outcome: Behaviour, problem.
Three separate meta-analyses were conducted in this domain. One
focused on activities of daily living (ADL) and basic self-care skills;
a second focused on behaviours seen as a problem, such as irritabil-
ity, being demanding and difficult. The third included ’general’
behaviour rating scales, which may include some of the previous
two aspects, together with some higher level daily living skills.
Four studies, involving 160 participants, used ADL scales. There
was no benefit identified with cognitive stimulation (SMD 0.21,
95% CI -0.05 to 0.47) (Z = 1.56, P = 0.12). Three studies, in-
cluding 166 participants, used scales evaluating behaviour prob-
lems. Again there was no difference related to cognitive stimula-
tion (SMD -0.14, 95% CI -0.44 to 0.17) (Z = 0.86, P = 0.39).
General behaviour rating scales showed a similar picture, with no
difference emerging. Eight studies, including 416 participants, re-
ported data on relevant scales (SMD 0.13, 95% CI -0.07 to 0.32)
(Z = 1.30, P = 0.20).
Caregiver outcomes
(See Figure 12)
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Figure 12. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment,
outcome: Caregiver outcome.
Three studies reported on outcomes for family caregivers. The
largest of these (Onder 2005) taught family caregivers to deliver the
cognitive stimulation, so the effects on caregivers were especially
pertinent for that study. The effect sizes for anxiety, depression and
caregiver burden were all close to zero (SMDs 0.11, 0.04, -0.03
respectively), with confidence intervals crossing zero indicating
no differences between the caregivers in the cognitive stimulation
condition and those in the control conditions.
Only one study (Baines 1987) reported outcomes for care staff, so
no meta-analysis was possible. The results of this study indicated
a significant increase in staff knowledge about residents partici-
pating in the cognitive stimulation intervention compared with
knowledge of residents in the control condition.
Follow-up
The analyses for assessments carried out after the intervention had
been completed were reported in two groups: Baines 1987 and
Wallis 1983 had a one month follow-up, and Baldelli 1993a a
three month follow-up on certain measures. These three studies
represent a short term follow-up; whereas Chapman 2004 reported
useable data only from a 10 month follow-up, a much longer
period in the context of the progression of dementia.
For cognitive measures (Figure 13), the three older studies with
short term follow-up reported data for 52 participants. The signif-
icant advantage for cognitive stimulation on cognitive measures
seen immediately post-treatment remained at this point (SMD
0.57, 95% CI 0.01 to 1.14) (Z = 2.00, P = 0.05). For the 54
participants included by Chapman 2004, there was no significant
effect on either the MMSE (SMD 0.18) or the ADAS-Cog (SMD
0.12) at the 10 month follow-up.
18Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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Figure 13. Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up,
outcome: Cognition.
For self-report well-being and quality of life measures (Figure
14), the only short term follow-up data came from Baines 1987,
with only 10 participants, and showed no differences. The longer
term follow-up from Chapman 2004 showed a SMD of 0.34 for
the QoL-AD measure but this difference was not significant. No
measures of mood were included in the studies reporting follow-
up.
Figure 14. Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up,
outcome: Well-being & Quality of Life.
19Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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For general behaviour rating scales (Figure 15), two studies re-
ported short term follow-up, with 29 participants. The SMD of
0.44 was not significant. Similarly at 10 months the scale used by
Chapman 2004 showed a non-significant SMD of 0.43. A similar
picture appeared in relation to problem behaviour (Figure 16),
where there was only one small study in the short term follow-
up group (Baines 1987) and the longer term follow-up reported
by Chapman 2004 did not show a significant difference on either
the Neuropsychiatric Inventory (NPI) severity score (SMD 0.29)
or the caregiver distress score related to the problem behaviour
(SMD 0.41).
Figure 15. Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up,
outcome: Behaviour, general.
Figure 16. Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up,
outcome: Behaviour, problem.
20Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Finally, there were no differences in measures of communication
and interaction (Figure 17) at either short term (Baines 1987) or
longer term follow-up (Chapman 2004).
Figure 17. Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up,
outcome: Communication and social interaction.
D I S C U S S I O N
In total, 15 RCTs with a total of 718 participants (407 receiving
cognitive stimulation, 311 in control groups) met the inclusion
criteria for the meta-analyses. The most striking finding reflects
the effects of cognitive stimulation on performance in tests of cog-
nitive function. The results of the meta-analyses reported here in-
dicate that cognitive stimulation programmes for dementia have
a significant positive effect on cognition, which is evident in the
post-2000 studies included in this review as well as in the older
studies which were included in our previous review of Reality Ori-
entation. This is perhaps the most consistent finding in the liter-
ature on psychological interventions with people with dementia.
The studies included here came from a variety of countries and
contexts, from France, the UK, Italy, Spain and Brazil; from hospi-
tal, care home, nursing home, day centre and outpatient settings;
and administered in groups by staff or volunteers, or individually
by family caregivers.
The extent to which these changes in cognitive function are clini-
cally important has not been generally addressed. An average ben-
efit of 1.74 points on the MMSE or 2.27 points on the ADAS-
Cog can be taken to indicate a slowing down of the rate of de-
cline, which has been estimated, in mild to moderate dementia,
to be between 2 and 4 points on the MMSE per annum (Mohs
2000). In relation to the number needed to treat (NNT) for one
more participant in the treatment group than in the control group
to benefit by a certain amount, Spector 2003 and Onder 2005
provide some evidence. For an improvement of 4 or more points
on the ADAS-Cog, Spector 2003 calculated an NNT of 6, and
Onder 2005 14, figures broadly comparable to those seen in trials
of the ACHEIs.
However, as has been pointed out repeatedly over the years (Woods
2006), changes in cognition are not sufficient to justify an exten-
sive programme of intervention, unless they are accompanied by
other changes, in behaviour and well-being. Here there are two
positive findings. Firstly, results from four RCTs (with 223 par-
ticipants) indicated that positive changes in communication and
social interaction were evident in staff ratings outside the context
of the cognitive stimulation group sessions. Secondly, results from
four RCTs (219 participants) identified a benefit on quality of life
and well-being associated with cognitive stimulation.
In contrast, there was no indication that cognitive stimulation was
associated with changes in mood, whether self-rated or rated by
staff, or in behaviour including activities of daily living and self-
21Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
care and problem behaviour. It is notable that in general there is
much less evidence available regarding these domains compared
with that available for changes in cognition. No benefits to family
caregivers were identified in terms of mood or caregiver burden.
However, it is important to note that in the study where the re-
sponsibility for delivering the cognitive stimulation fell on famiy
caregivers (Onder 2005), this additional task did not appear to
add to their stress and strain. One study showed an improvement
in care home staff knowledge of residents following participation
in cognitive stimulation.
There is little evidence available on the cost-effectiveness of cog-
nitive stimulation (CST). Knapp 2006 reported cost-effective-
ness acceptability curves for cognition and quality of life from the
Spector 2003 trial and conclude that, for both outcomes, ’under
reasonable assumptions, there is a high probability that CST is
more cost-effective than treatment as usual’.
These findings all relate to the assessment point immediately af-
ter the treatment period has been completed. Only four relatively
small studies reported data on whether any changes were main-
tained after a period of follow-up without further intervention.
Here, again, cognition stands out with three RCTs showing a pos-
itive effect evident at a follow-up of one to three months after
the intervention; this was not evident in the one RCT reporting a
10 month follow-up. Other follow-up data were limited in their
extent and scope but there were no indications of benefits in the
areas of behaviour and well-being that were evaluated.
A key area of difference between studies relates to the duration
and frequency of the cognitive stimulation offered, leading to a
wide variation in the ’dosage’ of cognitive stimulation received, as
indicated by the total number of hours of stimulation offered. As
pointed out previously, there does not appear to be a clear relation-
ship between dosage and the effect size on cognitive function in the
various studies; the Spearman’s correlation was 0.25 (N = 14, P =
0.392). It is difficult to ascertain whether the frequency of sessions
per week makes a difference as the study with the largest effect
sizes (Requena 2006) has five 45-minute sessions per week and
has the longest duration. As the duration increases, the anticipated
decline associated with dementia should tend to reduce the effects
of cognitive stimulation, and so a simple linear relationship is un-
likely to hold. One study (Requena 2006) continued cognitive
stimulation for two years. The decision was made to include one
year data from this study in the primary meta-analyses reported
here, to reduce the impact of attrition. However, the effects on
cognition and self-reported mood appeared to be sustained over a
further one year period, although the effects were not statistically
significant in our analyses. There is a need for further research
on maintenance cognitive stimulation, looking at whether lower-
intensity input maintains gains from an initial period of cognitive
stimulation (Aguirre 2010).
In five of the included studies all of the participants were pre-
scribed ACHEI medication. For the four of these RCTs providing
post-treatment data, the additional effect of cognitive stimulation
over and above the medication was 3.18 points on the ADAS-
Cog, compared with the overall finding (from seven RCTs) of 2.27
points. This supports the proposition that cognitive stimulation
is effective irrespective of whether or not ACHEIs are prescribed,
and any effects are in addition to those associated with the med-
ication. One study (Requena 2006) reported comparative results
from a control group who received neither cognitive stimulation
nor an ACHEI, but this was not a randomly allocated condition
so that the additive effects of these two treatment approaches were
not established compared with no treatment. Such a study would
perhaps not now be seen as ethical in a context where ACHEIs are
seen as standard treatment for Alzheimer-type dementia.
In general, it appears that outcome measures rated by staff are less
likely to indicate positive change than those that are completed by
the person with dementia directly with an assessor blinded to the
treatment received. In a care home or hospital context, it is well
known that achieving consistent staff ratings in research studies
such as these is a major challenge. It can often be impossible to
have the same staff member rate the person at each time point due
to staff turn-over and sickness. There can be a ’drift’ in ratings over
time, even with the same rater. The observation period and op-
portunities for observation may vary over time. Maintaining staff
blind to treatment allocation is more challenging than for an as-
sessor who only visits the facility to carry out the assessments. The
one area of staff-rated behaviour showing change in this review re-
lates to communication and social interaction, an area that has not
been highlighted in previous reviews of this type of intervention.
Given the social emphasis of cognitive stimulation groups, this is
an area of behaviour that is most closely linked to the content of
the intervention. Indeed, Spector 2010 have demonstrated that
in their study language function was an area of specific cognitive
improvement.
Inevitably where the control condition is ’no treatment’, the ques-
tion is raised as to whether any benefits associated with the treat-
ment arise from non-specific effects such as meeting as a group,
socialising, increased attention and so on. A few early studies did
include an ’attention’ control group (Woods 1979) or diversional
occupational therapy (Wallis 1983) and one study offered physi-
cal rehabilitation sessions to both groups (Baldelli 2002). In the
Requena 2006 study where stimulation materials were presented
on a TV screen to the group, control participants watched TV
elsewhere. Although we cannot provide a definitive conclusion on
this matter, our results did not indicate any effects of these dif-
ferent control conditions on outcome. In a mediation analysis,
Woods 2006 demonstrated that in the Spector 2003 RCT the im-
provements in quality of life were mediated by improvements in
cognition, suggesting that it is the cognitive focus of the cognitive
stimulation therapy programmes (rather than merely the social
contact and attention) which lead to improved well-being. Fur-
22Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ther work is required to explore the relationship between changes
in cognition and the changes in well-being and quality of life and
communication that are emerging from the current review.
The quality of the included studies is variable, and generally low,
with lack of clarity regarding randomisation procedures being evi-
dent in around half the studies (including some of the more recent
studies). CONSORT type diagrams depicting the flow of partic-
ipants through the trial are provided by four of the recent studies
(Bottino 2005; Buschert 2011; Onder 2005; Spector 2003) and,
along with remote, independent randomisation, will be a mini-
mum expectation in future trials. The number of participants in-
cluded has increased markedly from an average of 23 per study
prior to 2000 to 64 in the nine more recent studies. Larger sample
sizes will necessitate multi-centre trials, for example Spector 2003
recruited from 23 centres. This will have implications for analy-
ses, with cluster effects within a centre, even though participants
are individually randomised. Spector 2003 accordingly included
centre as a covariate in their analyses. Studies do not yet appear
to have taken account of clustering effects arising from a group
intervention. This occurs where changes in group members are
not entirely independent. Group leaders often report that some
groups seem to work much better than others for example. Inten-
tion-to-treat analyses were only described by two (recent) studies,
although in most cases details of attrition were reported. The need
for assessors to be blind to treatment allocation is widely recog-
nised and attempted in most studies. More attention may need to
be given in future studies to demonstrating the extent to which
the cognitive stimulation is delivered as planned. Well-developed
treatment manuals will help with assuring the replicability of the
intervention. In general, there is a clear improvement in overall
quality of the included studies over time, for example in the more
consistent information given regarding the diagnosis of partici-
pants and the criteria used, as well as the use of consistent outcome
measures and larger sample size.
The studies included in the review utilised therapists with a variety
of backgrounds, experience and training. They included volun-
teers, family caregivers, speech and language therapists, occupa-
tional therapists, nurses, care workers and research staff. There are
no indications from this review of the amount or type of training
required to deliver cognitive stimulation, although there is broad
agreement that whilst training is needed the therapist does not
need a professional qualification. Given the concerns regarding RO
being delivered in a mechanical, dehumanising fashion (Dietch
1989), training and supervision in person-centred care would be
seen as a prerequisite for delivery of cognitive stimulation. In this
review, there were no reported side effects or adverse effects of any
of the cognitive stimulation interventions. Attrition was due to
expected reasons in studies of this nature: illness, death, transfer to
another facility and occasional refusal to complete follow-up as-
sessments. With only one study utilising an individual approach,
in contrast to offering group cognitive stimulation, it is not possi-
ble to draw on any evidence on the strengths and benefits of these
different treatment modalities.
The range of severity of dementia experienced by patients in-
cluded in the studies reviewed here ranged from mild to moder-
ate. There was no indication that the two studies with the lowest
mean MMSE scores of participants (Spector 2001; Spector 2003)
had any different effects than those with more mildly impaired
participants. Most studies included a mixture of participants with
mild and moderate dementia. Onder 2005 indicated that there
was no differential benefit to either group, with no significant in-
teraction between severity of dementia and treatment on change
in either MMSE or ADAS-Cog scores. More work may be needed
to define if there are people with dementia, or subgroups, who
are more or less likely to benefit from a cognitive stimulation in-
tervention. No analyses have been attempted here seeking to es-
tablish whether different subtypes of the dementias show specific
responses to cognitive stimulation. One study (Baldelli 2002) in-
cluded only participants who had had a cerebrovascular accident
(CVA), although less than half the participants had a diagnosis of
vascular dementia. Most recent studies have included those who
are receiving AChEI medication, with a probable Alzheimer’s diag-
nosis, whereas Spector 2003 included all types of dementia. Given
that the average age of participants across the review was almost
80 years (over 85 in the Spector 2003 study), it is highly likely that
neurodegenerative and vascular changes are co-occurring in the
majority of participants, and so the distinction may be of limited
pragmatic utility.
The findings of this review are broadly in line with other more
wide-ranging reviews of non-pharmacological interventions in de-
mentia. Livingston 2005 gives a relatively strong recommendation
for cognitive stimulation in relation to its effects on neuropsychi-
atric symptoms, including mood, but notes some inconsistencies
in the evidence on these outcomes. Sitzer 2006 included 17 studies
in their meta-analysis of ’cognitive training’ in Alzheimer’s disease,
four of which met our definition of ’cognitive stimulation’ and
three of which are included in this review. Sitzer 2006 concludes
that there is a medium effect size (0.47) across all types of ’train-
ing’ over the whole range of outcome measures, making ’cogni-
tive training’ a promising intervention. However, it is notewor-
thy that general stimulation techniques were prominent in four
of the five trials reporting the most beneficial results, with the
review describing these as ’restorative strategies’. Olazaran 2010
reviewed 179 RCTs across 26 categories of non-pharmacological
interventions. They concluded that there was ’Grade B’ evidence
(consistent evidence from lower quality RCTs) for cognitive stim-
ulation in relation to cognition, behaviour and psychological well-
being. They did not identify any ’Grade A’ evidence (consistent ev-
idence from high quality RCTs) for any interventions with people
with dementia, although some caregiver interventions did reach
this level. The 2011 World Alzheimer’s Report (Prince 2011) con-
cludes, from a wide-ranging systematic review, “We found strong
23Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
evidence (multiple RCTs) that acetylcholinesterase inhibitors (for
cognitive function, functional impairment), and cognitive stimu-
lation (for cognitive function) are effective interventions in mild
dementia” and makes the following recommendation in relation
to interventions for early-stage dementia: “Acetylcholinesterase in-
hibitors and cognitive stimulation may enhance cognitive func-
tion in people with mild Alzheimer’s disease, and these interven-
tions should therefore be routinely offered.”
Finally, consideration should be given to the possibility of publica-
tion bias in this domain. By reviewing only the studies on cognitive
stimulation that have been published in peer-reviewed journals, it
must be acknowledged that these could represent a biased sample
of the studies undertaken world-wide on this topic. In many fields
of endeavour, trials that are not successful (that is do not produce
the expected positive findings) are less likely to be published. This
may be especially the case with smaller trials. The welcome trend
to pre-registration of trials, and the publication of trial protocols,
makes this less likely to occur in the future in relation to larger,
well-funded trials. The meta-analyses here have been influenced
strongly by the larger trials included (such as Spector 2003 and
Onder 2005), and a funnel plot of the cognition outcome appears
reasonably symmetrical (Figure 18) suggesting that possible pub-
lication bias is not a strong factor for this outcome at least.
Figure 18. Funnel plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-
treatment, outcome: 1.1 Cognition.
A U T H O R S ’ C O N C L U S I O N SImplications for practice
The evidence base for the effectiveness of cognitive stimulation
therapy for dementia in relation to cognitive function has been
consistently demonstrated, with small changes reported in multi-
ple trials on commonly used brief measures of cognitive function;
adverse effects have not been reported. There is now evidence from
a small number of studies that cognitive stimulation may also be
associated with improvements in quality of life and communica-
tion. These benefits are over and above any medication effects.
24Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
This review is consistent with the NICE-SCIE 2006 Guideline
recommendation that all people with mild to moderate demen-
tia should have the opportunity to participate in cognitive stim-
ulation groups, irrespective of whether or not they are receiving
acetylcholinesterase inhibiting medication (ACHEIs). This rec-
ommendation was recently reinforced by the World Alzheimer’s
Report (Prince 2011).
Although more research is needed, results from one study suggest
that continuing involvement in cognitive stimulation may be ben-
eficial.
Implications for research
There are a number of areas, relating to both theory and practice,
where further research is required. Now that its effects are becom-
ing better established, the theoretical basis of cognitive stimulation
would benefit from fuller investigation. This would involve study-
ing cognitive changes both in relationship to neural processes and
pathways; and their linkage, if any, with outcomes such as mood,
quality of life, day-to-day function and behaviour.
There is a clear need for more randomised controlled trials of cog-
nitive stimulation exploring the long term benefits of this inter-
vention. The effects of severity of dementia and different modali-
ties (for example group versus with caregiver) need to be system-
atically evaluated. These RCTs may be of particular value if used
in conjunction with more qualitative studies in order to under-
stand the relationships between the different outcome measures.
The clinical meaningfulness of any benefits needs to be examined,
particularly in relation to the impact of any cognitive changes. Are
there benefits in terms of increased participation in activities of
importance to the person, increased social inclusion or of individ-
ual goals being attained?
Only one cost-effectiveness study has been identified to date and
this gap should be addressed, particularly in relation to clinically
meaningful benefits.
Finally, the implementation of cognitive stimulation in real-life
settings needs to be addressed. The key issue here is whether the
results obtained by those who attend brief training in the methods
or make use of one of the treatment manuals that have been de-
veloped, or both, are comparable to those obtained in the context
of research studies and RCTs.
A C K N O W L E D G E M E N T S
Maintenance Cognitive Stimulation Programme (IS-
RCTN26286067) is part of the Support at Home - Interventions
to Enhance Life in Dementia (SHIELD) project (Application No
RP-PG-0606-1083) which is funded by the NIHR Programme
Grants for Applied research funding scheme. The grant holders
are Professors Orrell (UCL), Woods (Bangor), Challis (Manch-
ester), Moniz-Cook (Hull), Russell (Swansea), Knapp (LSE) and
Dr Charlesworth (UCL). The views and opinions expressed in this
review are those of the authors and do not necessarily reflect those
of the Department of Health/NIHR. The authors wish to thank
Joanne Knowles for acting as consumer reviewer for this review.
R E F E R E N C E S
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27Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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Spector 2000a
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effectiveness. Gerontologist 2000;40(2):206–212.∗ Indicates the major publication for the study
31Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Baines 1987
Methods RCT
Cross-over design: (only results from first phase are included in this review)Treatment 1: 4 weeks; 4 week ’wash-out’ period’; Treatment 2: 4 weeks
Participants N=15 (14F, 1M)
’Moderate to severe Impairment of cognitive functioning’
Mean age=81.5 (range 72-90)
Living in care home
Interventions RO
Reminiscence
Treatment as usual
Outcomes Cognitive: Information/Orientation & Mental Ability (CAPE)
Behaviour: Behavioural Rating Scale (CAPE)
Well being: Life Satisfaction Index;
Problem Behaviour Rating Scale
Communication : Holden Communication Scale
4 week follow-up data available
Staff completed ’Personal Information Questionnaire’, evaluating staff knowledge of
residents
Notes Treatment duration 30 minute sessions, 5 days a week for 4 weeks
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk No details of the randomisation method
used reported in the paper
Allocation concealment (selection bias) Unclear risk No details of the randomisation method
used reported in the paper
Blinding (performance bias and detection
bias)
All outcomes
Low risk RO groups held in separate areas;
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Cognitive assessments made by an inde-
pendent psychologist; other ratings made
by staff not involved in the therapy groups
Incomplete outcome data (attrition bias)
All outcomes
Low risk No attrition at follow-up assessment
32Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Baldelli 1993a
Methods RCT
Participants N=23 (23F/0M)
Alzheimer’s (SDAT)
Mean MMSE 20.6 (sd 4.9)
Mean age 84.5 (range 75-94)
All resident in institution
Interventions RO
Treatment at usual
Outcomes Cognition: MMSE; Berg Orientation Scale
Mood: GDS-30
ADL: Stewart ADL scale
3 month follow-up data on cognitive measures
Notes 60 minutes, 3 times a week for 3 months
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Stated by e-mail that their trials were randomised (with no detail
of the methods used)
Allocation concealment (selection bias) Unclear risk Stated by e-mail that their trials were randomised (with no detail
of the methods used)
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk No evidence of blinding in the paper
Blinding of outcome assessment (detection
bias)
All outcomes
Unclear risk No details of who assessors were
Incomplete outcome data (attrition bias)
All outcomes
Low risk Zero attrition at 3 month post-treatment assessment; no attrition
reported at follow-up 3 months later
Baldelli 2002
Methods RCT
Participants N= 87 (61F/26M)
’Degenerative senile dementia of the Alzheimer’s type (SDAT)’ (N=46) and “vascular
multi-infarct dementia” (N=41)
Mean MMSE 20.7 (sd 3.0)
Mean age 80.0 (range 65-97)
Resident in sub-acute care nursing home
33Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Baldelli 2002 (Continued)
All had at least elementary schooling
’All had comorbid conditions consisting of vascular accidents with acute motor deficits
of recent onset’
Interventions RO + physical therapy programme.
Physical therapy programme only
Outcomes Cognition: MMSE
Mood: Geriatric Depression Scale (GDS 30)
ADL: Barthel
Notes 60 minutes, 5 days per week for one month
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Stated by e-mail that their trials were randomised (with no detail
of the methods used)
Allocation concealment (selection bias) Unclear risk Stated by e-mail that their trials were randomised (with no detail
of the methods used)
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk No evidence of blinding in the paper
Blinding of outcome assessment (detection
bias)
All outcomes
Unclear risk No details of assessors given
Incomplete outcome data (attrition bias)
All outcomes
Low risk No attrition reported
Bottino 2005
Methods RCT
Participants N=13 (9F / 4M)
’Mildly impaired probable Alzheimer’s diagnosis’
All participants taking rivastigmine 6-12mg/day for 2 months
Mean MMSE 22.31 (sd 3.61; range 16-28)
Age 73.7 (range 62-83)
Out-patients
Interventions ’cognitive rehabilitation’ plus rivastigmine; carers attended a support group at same time
Treatment as usual: rivastigmine plus 30 minute monthly consultation with doctor in
relation to medication
34Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bottino 2005 (Continued)
Outcomes Participants:
Cognition: MMSE; ADAS-Cog,
ADL (rated by carer)
Carers’ mood: Hamilton Anxiety and Montgomery-Asberg Depression Rating Scales
Notes 90 minutes, once a week, for 5 months
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Randomised blocks design, randomly allocated to either group
by telephone by an assessor blind to the patient group
Allocation concealment (selection bias) Low risk Randomised blocks design, randomly allocated to either group
by telephone by an assessor blind to the patient group
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Assessment made by assessors blinded to group allocation
Incomplete outcome data (attrition bias)
All outcomes
Low risk No attrition reported
Breuil 1994
Methods RCT
Participants N= 61 (37F / 24M)
Diagnosis of dementia (DSM-III) (90% have Alzheimer’s Disease)
Age 77.1 (range 61-93)
Mean MMSE 21.5 (range 9-29)
Out-patients
Interventions Cognitive stimulation
Treatment as usual
Outcomes Cognition: MMSE, CERAD
ADl: ECA scale rated by family members
Notes 60 minutes, 2 times a week, for 5 weeks
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk No details of randomisation reported
35Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Breuil 1994 (Continued)
Allocation concealment (selection bias) Unclear risk No details of randomisation reported
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Cognitive assessments made by an assessor blind to group allo-
cation; ADL assessment open
Incomplete outcome data (attrition bias)
All outcomes
Low risk Five patients excluded as did not attend all training and evalua-
tion sessions (3 from treatment group, 2 from controls)
Buschert 2011
Methods RCT
Participants N=39
24 amnestic MCI; 15 mild Alzheimer’s disease (only data on Alzheimer’s patients reported
in this review) 8F/7M
Mean MMSE 24.9 (sd 1.6; range 22-27)
All on stable doses of AChEIs or memantine
Age 75.9 (sd 8.1)
Out-patients
Interventions Multi-component cognitive group intervention - for AD group emphasis on cognitive
stimulation (for MCI group more emphasis on cognitive training); Control group had
pencil and paper exercises for self-study and monthly meetings
Outcomes Cognition: MMSE; ADAS-Cog, Trail Making Test, RBANS story memory & recall
Quality of life: QoL-AD
Mood: Montgomery Asberg Depression Rating Scale
Notes 2 hours, once a week for 6 months (20 sessions)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Blocked randomisation procedure; participants pooled in pairs
with respect to age, gender, education and ApoE genotype, then
randomly assigned pairs to intervention or control using a com-
puterised random number generator
Allocation concealment (selection bias) Low risk Blocked randomisation procedure
Blinding of outcome assessment (detection
bias)
All outcomes
Unclear risk Assessors blind to group allocation
36Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Buschert 2011 (Continued)
Incomplete outcome data (attrition bias)
All outcomes
Low risk No attrition
Chapman 2004
Methods RCT
Participants N= 54 (29F / 25M)
probable AD, on stable dose of donepezil for at least 3 months
Mean MMSE 20.87 (sd 3.55, range 12-28)
Age 76.4 (range 54-91)
Living at home initially
Interventions cognitive stimulation + donepezil
Donepezil only
Outcomes Cognition: MMSE; ADAS-Cog;
ADL: Texas Functional Living Scale
Behavioural problems: NPI - Irritability and Apathy
Quality of Life: QoL-AD
Global functioning: CBIC
Verbalisation: Composite discourse score
Carer distress - derived from the NPI
10 month follow up data available
Notes 90 minutes, once a week, for 8 weeks
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Independent randomisation, using an SAS procedure
Allocation concealment (selection bias) Low risk Remote telephone randomisation
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk Carer ratings not blind to allocation
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk All raters underwent extensive training; assessors blinded to
group allocation
Incomplete outcome data (attrition bias)
All outcomes
Low risk Intention to treat analysis used. 24% attrition rate at end of
study
37Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Chapman 2004 (Continued)
Other bias Low risk Programme led by trained speech therapist, weekly meetings
held in order to ensure the programme is implemented as de-
signed
Coen 2011
Methods RCT
Participants N = 27 (14F/13M)
Dementia - MMSE 10-23
MMSE: 16.9 (sd 5.0)
Age: 79.8 (sd 5.6)
Groups ran in 2 long term care facilities and a private nursing home
Interventions Cognitive stimulation
No treatment
Outcomes Cognition: MMSE; ADAS-Cog
Quality of life: QoL-AD
Communication: Holden Communication Scale
Mood: Geriatric Depression Scale (14 item); RAID (Rating of Anxiety in Dementia)
Behaviour: Behaviour Rating Scale (CAPE)
Clinical Dementia Rating (sum of boxes)
Notes 45 minutes, 2 times a week for 7 weeks
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Stated that participants were randomly assigned. Author con-
firms computerised randomisation and random number tables
were used
Allocation concealment (selection bias) Unclear risk Stated that participants were randomly assigned. Author con-
firms computerised randomisation and random number tables
were used
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk Staff running groups also involved in other activities, involving
control participants
Blinding of outcome assessment (detection
bias)
All outcomes
Unclear risk Tests administered by staff blind to group membership. Not
clear if staff ratings were made by staff who wre blinded
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk No attrition
38Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Coen 2011 (Continued)
Other bias Unclear risk Sessions run by occupational therapists and activity coordinator
Ferrario 1991
Methods RCT
Participants N=19 (8F / 11M)
elderly patients with cognitive disturbances
MMSE range 18-25
Age 82.5 (sd 5.2)
Resident in institution
Interventions RO
No treatment
Outcomes Cognition: CAPE I/O
Self-care: MOSES
Behaviour problems: MOSES - irritable, withdrawn
Mood: MOSES
Notes 60 minutes, 5 times a week, for 21 weeks
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Stated by e-mail that the trial was randomised (with no detail of
the methods used)
Allocation concealment (selection bias) Unclear risk Stated by e-mail that the trial was randomised (with no detail of
the methods used)
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk No information given in relation to where groups were held,
but RO materials were in evidence on the ward - may have been
accessed by control participants?
Blinding of outcome assessment (detection
bias)
All outcomes
Unclear risk MOSES completed by nursing staff - not clear if raters were
blind
Incomplete outcome data (attrition bias)
All outcomes
Low risk 2 dropouts (/21). 1 in each group (pneumonia and stroke). (In-
formation provided by the author)
Other bias Low risk RO administered by volunteers trained by physicians and psy-
chologist
39Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Onder 2005
Methods RCT
Participants N = 156 (113F/ 43M)
Probable Alzheimer’s Disease, on Donepezil for at least 3 months
MMSE 20.1 (sd 3.1)
Age 75.8 (sd 7.1)
Living at home
Interventions RO + Donepezil
Donepezil only
Outcomes Cognition:MMSE; ADAS-Cog
ADL: Barthel; IADL
Behaviour problems: NPI
Family caregiver outcomes: Hamilton anxiety and depression scales; Caregiver Burden
Inventory; SF-36
Notes 30 minutes, 3 times a week, for 25 weeks; plus informal contacts 2 or 3 times a day
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Computerised block randomisation process
Allocation concealment (selection bias) Low risk Computerised block randomisation process
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Assessment made by blind assessors
Incomplete outcome data (attrition bias)
All outcomes
Low risk Attrition data reported: 9 from RO group, 10 from control group
i.e. 19%
Other bias Low risk Family caregivers trained by a multi-disciplinary team
Requena 2006
Methods RCT
Participants N = 86 (61F / 25M)
Alzheimer-type dementia (severe dementia excluded)
MMSE 21.3
Age 77 (sd 7.5)
Attending daycare centre
40Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Requena 2006 (Continued)
Interventions 1) Cognitive stimulation + Donepezil
2) Donepezil only
3) Cognitive stimulation only
4) No treatment
Outcomes Cognition: MMSE, ADAS-Cog
Mood: GDS-30
12 month and 24 month data reported
Notes 45 minutes, 5 times a week for 24 months
’No treatment’ group were not part of the randomisation process. Comparison of interest
to this review is cognitive stimulation + donepezil v donepezil alone
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Randomisation by registration order: ’subjects were randomly
distributed in groups at the time they arrived at the Centre’
Allocation concealment (selection bias) Unclear risk Randomisation by registration order
Blinding (performance bias and detection
bias)
All outcomes
Low risk Spanish paper stated that groups were led by an independent
member of the research team
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Spanish paper states ’Evaluator was blind to treatment allocation’
Incomplete outcome data (attrition bias)
All outcomes
Low risk Attrition reported: 6/20 in CS + donepezil group; 10/30 in
donepezil alone group i.e. 32% over 2 year period
Spector 2001
Methods RCT
Participants N = 35
Diagnosis of dementia according to DSM-IV criteria
MMSE 13.1 (sd 4.4)
Age 85.7 (sd 6.7)
Living at home: 12; living in residential home: 23
Interventions Cognitive stimulation
Treatment as usual
41Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Spector 2001 (Continued)
Outcomes Cognition: MMSE; ADAS-Cog
Communication: Holden Communication Scale
Mood: Cornell Scale for Depression in Dementia; RAID
Behaviour: Behaviour Rating Scale (CAPE).
Family caregivers: Relatives Stress Scale; GHQ
Notes 45 minutes, 2 times a week, for 7 weeks
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Randomly allocated to either group by drawing names from a
sealed container
Allocation concealment (selection bias) Low risk Randomly allocated to either group by drawing names from a
sealed container
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk Not clear whether staff and carer ratings were made blind to
treatment allocation
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Cognitive assessments made by a blind assessor
Incomplete outcome data (attrition bias)
All outcomes
Low risk Attrition reported: 4 in CS group, 4 in control group i.e. 23%
Other bias Low risk Groups led by a member of the research team in a separate room
for the programme in each of the centres
Spector 2003
Methods RCT
Participants N = 201 (158F / 43M)
Dementia (DSM-IV criteria) - MMSE 10-24
MMSE: 14.4 (sd 3.8)
Age: 85.3 (sd 7.0)
Groups ran in 18 residential homes; 5 day centres
Interventions Cognitive stimulation
No treatment
Outcomes Cognition: MMSE; ADAS-Cog
Quality of life: QoL-AD
Communication: Holden Communication Scale
42Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Spector 2003 (Continued)
Mood: Cornell Scale for Depression in Dementia
Behaviour: Behaviour Rating Scale (CAPE)
Notes 45 minutes, 2 times a week, for 7 weeks
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Randomly allocated to either group by drawing names from a
sealed container
Allocation concealment (selection bias) Low risk Randomly allocated to either group by drawing names from a
sealed container - would have been preferable for randomisation
to have been carried out independently
Blinding (performance bias and detection
bias)
All outcomes
Low risk Members of staff involved in groups did not carry out ratings,
but ratings by other staff may not have been blind
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Cognitive assessments and quality of life interview conducted
by a blind assessor
Incomplete outcome data (attrition bias)
All outcomes
Low risk 34/201 did not complete study (18 CS / 16 controls); 17%
attrition
Other bias Low risk Groups led by a member of the research team in a specific room
for the programme in each of the centres, with a member of staff
Wallis 1983
Methods RCT
Participants N = 60
31 ’Demented / organic’; 29 ’functional’ not included in this review
Age 69.8 (range 38-95)
All residents in long-stay psychiatric hospital
Interventions RO groups
Diversional Occupational Therapy - group and individual
Outcomes Cognition: Royal College of Physicians mental test score
Behaviour: Crichton Behaviour Rating Scale
One month follow up data available
Notes 30 minutes, 5 times a week, for 3 months
43Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wallis 1983 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Drawing from a hat and consecutive allocation
Allocation concealment (selection bias) Low risk Drawing from a hat and consecutive allocation
Blinding (performance bias and detection
bias)
All outcomes
Low risk Setting of treatment separate to assessment settings
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Assessors unaware of group allocation
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Eliminated those attending less than 20% of sessions; 12/31
participants in ’organic’ group lost i.e. 39%
Other bias Low risk Occupational therapists trained to carry out RO
Woods 1979
Methods RCT
Participants N = 18
’disorientated’, significant memory impairment
Age 76.6 (range 61-90)
All living in specialist residential homes for people with dementia
Interventions RO groups
Social Therapy groups
No treatment (in a different home, so not included in this review)
Outcomes Cognition: Wechsler Memory Scale; composite Information & Orientation test
Behaviour: modified Crichton Behaviour Rating Scale
Notes 30 minutes, 5 times a week, for 20 weeks
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Stated that drawing from a hat was used
44Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Woods 1979 (Continued)
Allocation concealment (selection bias) Unclear risk Stated that drawing from a hat was used
Blinding (performance bias and detection
bias)
All outcomes
Low risk ’Social therapy’ was perceived by staff as an active therapy
Blinding of outcome assessment (detection
bias)
All outcomes
Low risk Groups held in separate areas and assessors bind to group allo-
cation
Incomplete outcome data (attrition bias)
All outcomes
Low risk 4/18 dropped out: i.e. 22.2% attrition
Other bias Low risk Checks were made in order to ensure compliance with thera-
peutic protocol, including rating tape-recorded sessions
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Arcoverde 2008 Intervention doesn’t meet the inclusion criteria for cognitive stimulation. Diagnoses varied, not purely
dementia
Basak 2008 Intervention described doesn’t meet the inclusion criteria for cognitive stimulation; better fit for
cognitive training
Brook 1975 Does not include a measure of cognitive function.
Carlson 2008 Intervention described doesn’t meet the inclusion criteria for cognitive stimulation but for cognitive
training. Diagnoses varied, not purely dementia
Cassinello 2008 Doesn’t report an RCT, reports results from Tarraga 2001.
Cheng 2006 Intervention described doesn’t meet the inclusion criteria for cognitive stimulation
Constantinidou 2008 Intervention described doesn’t meet the inclusion criteria for cognitive stimulation
Corbeil 1999 Although intervention is described as “cognitive stimulation”, it focuses on specific cognitive modal-
ities. Primary reports outcomes for family caregivers, no measure of cognitive function. Relates to
Quayhagen, 1995
Croisile 2006 Doesn’t report results from an RCT.
Davis 2001 Cognitive stimulation (delivered for 30 minutes a day, 6 days a week by family caregivers) confounded
with cognitive training-spaced retrieval and face name associations
45Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Eckroth-Bucher 2009 Intervention doesn’t meet the inclusion criteria for cognitive stimulation. Diagnoses varied, not purely
dementia
Eggermont 2009a Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Eggermont 2009b Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Evans 2009 Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Faggian 2007 Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Fanto 2002 No mention of randomisation; available only as a conference abstract
Farina 2006a Non randomised allocation; comparison is with an active treatment group
Farina 2006b Non randomised allocation; comparison is with an active treatment group
Forbes 2004a Commentary on Spector 2003.
Gerber 1991 Eligible study, but no extractable data provided. Only data available is for a composite cognitive and
behavioural scale
Goldstein 1982 Around 25% of participants appear not to have dementia, other diagnoses include schizophrenia,
epilepsy and ruptured aneurysm
Gonzalez-Abraldes 2010 Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Green 2009 Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Greenaway 2008 Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Hanley 1981 Eligible study, but no extractable data available
Hernandez, 2007 Reports on Requena 2006 study results. Article in Spanish.
Hirsch 2004 Reports on Spector 2003 results.
Holden 1978 Diagnoses varied, not purely dementia. Not clear that participants were randomised to the intervention
and control groups
Johnson 1981 Allocation of patients to treatment was not random for various practical reasons
Leach 2004 Commentary on Spector 2003.
Matsuda 2007 Non-randomised study.
Meza-Kubo 2009 Not a randomised control trial.
46Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Milev 2008 Intervention doesn’t meet the inclusion criteria for cognitive stimulation - relates to ’snoezelen’
Moniz-Cook 2006 Reference to other studies in cognitive stimulation (e.g. Spector 2003) but not a new RCT
Mudge 2008 Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Newson 2006 Intervention doesn’t meet the inclusion criteria for cognitive stimulation. Diagnoses varied, not de-
mentia
Olazaran 2004 12/84 participants with a diagnoses of MCI; results not presented separately for those with Alzheimer’s
disease.Interventions include additional elements as physical exercise
Orrell 2000b Describes study aims for Spector 2003.
Orrell 2005 Allocation to intervention and control groups not random for maintenance study
Quayhagen 1995 Although intervention is described as cognitive stimulation, it appears to focus on specific cognitive
modalities, and so fits better with cognitive training definition
Quayhagen 2000 Although intervention is described as cognitive stimulation, it appears to focus on specific cognitive
modalities, and so fits better with cognitive training definition
Raggi 2007 Not RCT.
Reeve 1985 No indication of random allocation to groups.
Riegler 1980 Comparin of RO plus music versus RO. No control groups without RO
Ruiz Sanchez de Leon 2007 No RCT and intervention doesn’t meet the criteria for inclusion under cognitive stimulation
Salmon 2006 No RCT, reports on Spector 2003 trial results.
Schmitter-Edgecombe 2008 Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Schreiber 1998 Cognitive training, targeting specific cognitive modalities, rather than cognitive stimulation. Allocation
to groups alternate, not random
Schreiber 1999 See Schreiber 1998.
Scott 2003 Doesn’t report on a study intervention. No RCT.
Smith 2009 Intervention doesn’t meet the inclusion criteria for cognitive stimulation
Spector 2008 Reports on Spector 2003 results.
47Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Tadaka 2004 The intervention combines elements of Reality Orientation (RO) and reminiscence. The RO element
appears to be only an orientation board, used to reinforce orientation for time, place and person. The
reminiscence element appears to be predominant, with a variety of reminiscence based triggers, and
so the study would be a better fit for a review of reminiscence work with people with dementia
Tarraga 2005a Published as Tarraga 2006.
Tarraga 2005b Published as Tarraga 2006.
Tarraga 2006 Allocation to groups is not entirely random. For the comparison of interest, integrated psychostimu-
lation program versus medication only control, allocation is clearly non-random
Tarraga 2007 As in Tarraga 2006.
Thickpenny-Davis 2007 Intervention doesn’t meet the inclusion criteria for cognitive stimulation, participants included with
other diagnosis than dementia
Tsai 2008 Not RCT.
Wenisch 2005 Participants included with a diagnosis of MCI and not dementia
Wenisch 2007 As in Wenisch 2005.
Wettstein 2004 Does not report an intervention study.
Williams 1987 Not a RCT, compares two wards, not cognitive stimulation, involves environmental modification and
informal RO
Woods 2006 Report on Spector 2003 study results.
Zanetti 1995 Allocation non-randomised.
Zanetti 2004 As in Zanetti 1995.
Zepelin 1981 Not a RCT, compares residents at one home with those in another
Zientz 2007 Does not report an intervention study.
Characteristics of studies awaiting assessment [ordered by study ID]
48Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Buettner 2011
Methods RCT
Participants N=77 (15M/62F)
Community dwelling
Mild memory loss - probable early stage Alzheimer’s
MMSE 25.3
Interventions Classroom style ’Mentally Stimulating Activities’ v Structured early-stage social support programme
Outcomes Cognition: MMSE, Trail Making B
Quality of life: Cornell-Brown QoL
Depression: PHQ-9
Apathy Evaluation Scale
Notes Sessions 1 hour, twice weekly for 4 weeks
Fernandez-Calvo 2010
Methods RCT
Participants N=45
Probable Alzheimer’s
MMSE 18.97
Interventions Individual multimodal cognitive stimulation versus group multimodal cognitive stimulation versus no treatment
control
Outcomes Cognition: ADAS-Cog
NPI
Cornell Depression Scale
Notes In Spanish
Niu 2010
Methods RCT
Participants N=32
mild to moderate Alzheimer’s with marked neuropsychiatric symptoms
MMSE 17.1
Inpatients in military sanatorium
All on donepezil
Interventions Individual sessions, task based including reality orientation, fluency, and memory tasks
Placebo control - communication exercise
Outcomes Cognition: MMSE
NPI, apathy, depression
49Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Niu 2010 (Continued)
Notes 45 minutes, twice a week for 10 weeks
Characteristics of ongoing studies [ordered by study ID]
Aguirre 2010
Trial name or title MCST - maintenance cognitive stimulation
Methods RCT
Participants Target N=230
Diagnosis of dementia with DSM-IV criteria
Mild to moderate dementia
Interventions All participants receive 7 weeks of twice weekly cognitive stimulation; then randomised to recive 6 months
of once weekly maintenance cognitive stimulation
Outcomes Cognition: ADAS-Cog, MMSE
Quality of Life: QoL-AD, DEMQOL
Starting date
Contact information [email protected]
Notes ISRCTN 26286067
Vidovich 2011
Trial name or title PACE-AD
Methods RCT
Participants Target N=128
probable Alzheimer’s
Interventions Cognitive activity groups for person with dementia and companion together v companions alone
Outcomes Cognition: ADAS-Cog
Companion quality of life, mood, and general health
Starting date
Contact information [email protected]
Notes Trial registration: ACTRN 12610000653066
50Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D A T A A N D A N A L Y S E S
Comparison 1. Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Cognition 14 658 Std. Mean Difference (IV, Fixed, 95% CI) 0.41 [0.25, 0.57]
1.1 ADAS-Cog 7 434 Std. Mean Difference (IV, Fixed, 95% CI) 0.37 [0.17, 0.56]
1.2 Wechsler Memory Scale 1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.47 [-0.80, 1.74]
1.3 Global cognitive score
(includes MMSE & CERAD)
1 56 Std. Mean Difference (IV, Fixed, 95% CI) 0.63 [0.09, 1.17]
1.4 MMSE 2 110 Std. Mean Difference (IV, Fixed, 95% CI) 0.64 [0.17, 1.10]
1.5 CAPE-I/O 2 29 Std. Mean Difference (IV, Fixed, 95% CI) 0.29 [-0.48, 1.06]
1.6 RCP Cognition 1 19 Std. Mean Difference (IV, Fixed, 95% CI) 0.13 [-0.78, 1.03]
2 MMSE 10 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 One to twelve months of
CS
10 600 Mean Difference (IV, Fixed, 95% CI) 1.74 [1.13, 2.36]
2.2 24 months of CS 1 29 Mean Difference (IV, Fixed, 95% CI) 5.99 [-1.58, 13.56]
3 ADAS-Cog 7 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.1 One to twelve months of
CS
7 434 Mean Difference (IV, Fixed, 95% CI) 2.27 [0.99, 3.55]
3.2 24 months of CS 1 29 Mean Difference (IV, Fixed, 95% CI) 11.94 [-0.97, 24.85]
4 Other cognitive measure:
Information/Orientation
5 81 Std. Mean Difference (IV, Fixed, 95% CI) 0.45 [-0.01, 0.90]
4.1 CAPE I/O 2 29 Std. Mean Difference (IV, Fixed, 95% CI) 0.29 [-0.48, 1.06]
4.2 RCP Cognition 1 19 Std. Mean Difference (IV, Fixed, 95% CI) 0.13 [-0.78, 1.03]
4.3 Berg Orientation Scale 1 23 Std. Mean Difference (IV, Fixed, 95% CI) 0.87 [0.00, 1.74]
4.4 Information / Orientation 1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.60 [-0.68, 1.89]
5 Comunication and social
interaction
4 223 Std. Mean Difference (IV, Fixed, 95% CI) 0.44 [0.17, 0.71]
5.1 Holden Communication
Scale
3 204 Std. Mean Difference (IV, Fixed, 95% CI) 0.47 [0.18, 0.75]
5.2 MOSES - Withdrawn
behaviour
1 19 Std. Mean Difference (IV, Fixed, 95% CI) 0.10 [-0.86, 1.07]
6 Well-being & Quality of Life 4 219 Std. Mean Difference (IV, Fixed, 95% CI) 0.38 [0.11, 0.65]
6.1 Life Satisfaction Index 1 10 Std. Mean Difference (IV, Fixed, 95% CI) -0.23 [-1.48, 1.01]
6.2 QoL-AD 3 209 Std. Mean Difference (IV, Fixed, 95% CI) 0.41 [0.13, 0.69]
7 Mood: Self-reported 5 201 Std. Mean Difference (IV, Fixed, 95% CI) 0.22 [-0.09, 0.53]
7.1 Geriatric Depression
Scale (GDS-30) One to twelve
months of CS
3 160 Std. Mean Difference (IV, Fixed, 95% CI) 0.34 [-0.01, 0.70]
7.2 Geriatric Depression
Scale (14 item) One to twelve
months of CS
1 26 Std. Mean Difference (IV, Fixed, 95% CI) -0.39 [-1.16, 0.39]
7.3 Montgomery Asberg
Depression Rating Scale
(MADRS) One to twelve
months of CS
1 15 Std. Mean Difference (IV, Fixed, 95% CI) 0.31 [-0.72, 1.33]
8 Mood: Staff-reported 4 239 Std. Mean Difference (IV, Fixed, 95% CI) 0.05 [-0.21, 0.31]
51Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
8.1 Cornell Scale for
Depression in Dementia
2 194 Std. Mean Difference (IV, Fixed, 95% CI) 0.01 [-0.28, 0.30]
8.2 MOSES - Depressed /
anxious mood
1 19 Std. Mean Difference (IV, Fixed, 95% CI) -0.01 [-0.98, 0.96]
8.3 Rating of Anxiety in
Dementia (RAID)
1 26 Std. Mean Difference (IV, Fixed, 95% CI) 0.38 [-0.40, 1.16]
9 ADL scales 4 260 Std. Mean Difference (IV, Fixed, 95% CI) 0.21 [-0.05, 0.47]
10 Behaviour, general 8 416 Std. Mean Difference (IV, Fixed, 95% CI) 0.13 [-0.07, 0.32]
10.1 CAPE - BRS 4 231 Std. Mean Difference (IV, Fixed, 95% CI) 0.12 [-0.14, 0.38]
10.2 Crichton BRS (modified) 2 29 Std. Mean Difference (IV, Fixed, 95% CI) 0.33 [-0.42, 1.07]
10.3 MOSES Self-care 1 19 Std. Mean Difference (IV, Fixed, 95% CI) 0.00 [-0.97, 0.97]
10.4 Instrumental ADL 1 137 Std. Mean Difference (IV, Fixed, 95% CI) 0.12 [-0.22, 0.46]
11 Behaviour, problem 3 166 Std. Mean Difference (IV, Fixed, 95% CI) -0.14 [-0.44, 0.17]
11.1 Problem Behaviour
Rating Scale
1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.40 [-0.86, 1.66]
11.2 MOSES - Irritable 1 19 Std. Mean Difference (IV, Fixed, 95% CI) 0.12 [-0.85, 1.09]
11.3 NPI 1 137 Std. Mean Difference (IV, Fixed, 95% CI) -0.20 [-0.54, 0.13]
12 Caregiver outcome 3 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
12.1 Hamilton anxiety 2 150 Std. Mean Difference (IV, Fixed, 95% CI) 0.11 [-0.21, 0.44]
12.2 Depression 2 150 Std. Mean Difference (IV, Fixed, 95% CI) 0.04 [-0.28, 0.36]
12.3 Carer stress/burden 2 147 Std. Mean Difference (IV, Fixed, 95% CI) -0.03 [-0.35, 0.29]
12.4 General Health
Questionnaire (GHQ-12)
1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.94 [-0.41, 2.29]
Comparison 2. Cognitive stimulation versus no cognitive stimulation: follow-up
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Cognition 4 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 One to three months
follow-up Information/
Orientation
3 52 Std. Mean Difference (IV, Fixed, 95% CI) 0.57 [0.01, 1.14]
1.2 Ten months follow-up
MMSE
1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.18 [-0.35, 0.72]
1.3 Ten months follow-up
ADAS-Cog
1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.12 [-0.41, 0.66]
2 Well-being & Quality of Life 2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 One month follow-up Life
Satisfaction Index
1 10 Std. Mean Difference (IV, Fixed, 95% CI) -0.03 [-1.27, 1.21]
2.2 Ten months follow-up
QoL-AD
1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.34 [-0.19, 0.88]
3 Behaviour, general 3 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.1 One month follow-up 2 29 Std. Mean Difference (IV, Fixed, 95% CI) 0.44 [-0.30, 1.18]
3.2 Ten months follow-up
Texas Functional Living Scale
1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.43 [-0.11, 0.97]
4 Behaviour, problem 2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
52Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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4.1 One month follow-up
Problem Behaviour Rating
Scale
1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.39 [-0.87, 1.65]
4.2 Ten month follow-up NPI
severity
1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.29 [-0.24, 0.83]
4.3 Ten-month follow up NPI
(Caregiver Distress)
1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.41 [-0.13, 0.95]
5 Communication and social
interaction
2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
5.1 One month follow-up
Holden Communication Scale
1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.20 [-1.05, 1.44]
5.2 Ten month follow-up
’Relevance of discourse’
1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.15 [-0.39, 0.68]
Analysis 1.1. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 1 Cognition.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 1 Cognition
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 ADAS-Cog
Bottino 2005 6 2.17 (8.33) 7 -0.43 (8.92) 2.1 % 0.28 [ -0.82, 1.38 ]
Buschert 2011 8 0.7 (8) 7 0 (6.93) 2.5 % 0.09 [ -0.93, 1.10 ]
Coen 2011 13 0.2 (7.2) 12 2.3 (4.1) 4.1 % -0.34 [ -1.13, 0.45 ]
Onder 2005 70 0.4 (6.69) 67 -2.5 (6.55) 22.5 % 0.44 [ 0.10, 0.77 ]
Requena 2006 20 6.4 (14.06) 30 -6.6 (20.48) 7.6 % 0.70 [ 0.12, 1.29 ]
Spector 2001 17 4.3 (17.33) 10 -1 (20.5) 4.2 % 0.28 [ -0.51, 1.06 ]
Spector 2003 97 1.9 (6.2) 70 -0.3 (5.5) 26.9 % 0.37 [ 0.06, 0.68 ]
Subtotal (95% CI) 231 203 70.0 % 0.37 [ 0.17, 0.56 ]
Heterogeneity: Chi2 = 4.88, df = 6 (P = 0.56); I2 =0.0%
Test for overall effect: Z = 3.74 (P = 0.00019)
2 Wechsler Memory Scale
Woods 1979 5 4.7 (12.02) 5 -0.6 (7.85) 1.6 % 0.47 [ -0.80, 1.74 ]
Subtotal (95% CI) 5 5 1.6 % 0.47 [ -0.80, 1.74 ]
Heterogeneity: not applicable
-4 -2 0 2 4
Favours control Favours CS
(Continued . . . )
53Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(. . . Continued)
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Test for overall effect: Z = 0.73 (P = 0.47)
3 Global cognitive score (includes MMSE % CERAD)
Breuil 1994 29 5.8 (7.3) 27 1 (7.8) 8.9 % 0.63 [ 0.09, 1.17 ]
Subtotal (95% CI) 29 27 8.9 % 0.63 [ 0.09, 1.17 ]
Heterogeneity: not applicable
Test for overall effect: Z = 2.29 (P = 0.022)
4 MMSE
Baldelli 1993a 13 3 (5.32) 10 -4.4 (9.15) 3.3 % 0.99 [ 0.11, 1.87 ]
Baldelli 2002 71 2.34 (4.78) 16 -0.12 (5.06) 8.6 % 0.50 [ -0.04, 1.05 ]
Subtotal (95% CI) 84 26 11.9 % 0.64 [ 0.17, 1.10 ]
Heterogeneity: Chi2 = 0.83, df = 1 (P = 0.36); I2 =0.0%
Test for overall effect: Z = 2.69 (P = 0.0071)
5 CAPE-I/O
Baines 1987 5 1.4 (4.59) 5 0.1 (6.4) 1.7 % 0.21 [ -1.03, 1.46 ]
Ferrario 1991 13 1.23 (3.64) 6 0 (2.93) 2.7 % 0.34 [ -0.63, 1.32 ]
Subtotal (95% CI) 18 11 4.4 % 0.29 [ -0.48, 1.06 ]
Heterogeneity: Chi2 = 0.03, df = 1 (P = 0.87); I2 =0.0%
Test for overall effect: Z = 0.74 (P = 0.46)
6 RCP Cognition
Wallis 1983 10 5.9 (35.5) 9 1.7 (27.04) 3.2 % 0.13 [ -0.78, 1.03 ]
Subtotal (95% CI) 10 9 3.2 % 0.13 [ -0.78, 1.03 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.27 (P = 0.78)
Total (95% CI) 377 281 100.0 % 0.41 [ 0.25, 0.57 ]
Heterogeneity: Chi2 = 7.98, df = 13 (P = 0.84); I2 =0.0%
Test for overall effect: Z = 5.04 (P < 0.00001)
Test for subgroup differences: Chi2 = 2.24, df = 5 (P = 0.82), I2 =0.0%
-4 -2 0 2 4
Favours control Favours CS
54Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.2. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 2 MMSE.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 2 MMSE
Study or subgroup Cognitive stimulation ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 One to twelve months of CS
Baldelli 1993a 13 3 (5.32) 10 -4.4 (9.15) 0.9 % 7.40 [ 1.03, 13.77 ]
Baldelli 2002 71 2.34 (4.78) 16 -0.12 (5.06) 5.1 % 2.46 [ -0.26, 5.18 ]
Bottino 2005 6 0.83 (4.53) 7 -1.43 (5.3) 1.3 % 2.26 [ -3.08, 7.60 ]
Breuil 1994 29 1.4 (2.7) 27 -0.7 (3.1) 16.1 % 2.10 [ 0.57, 3.63 ]
Buschert 2011 8 0.5 (3.14) 7 -0.9 (2.83) 4.1 % 1.40 [ -1.62, 4.42 ]
Coen 2011 14 0.8 (3.6) 11 -2.1 (2.5) 6.6 % 2.90 [ 0.50, 5.30 ]
Onder 2005 70 0.2 (3.35) 67 -1.1 (3.27) 30.6 % 1.30 [ 0.19, 2.41 ]
Requena 2006 20 1.5 (7.38) 30 -3.37 (10.71) 1.5 % 4.87 [ -0.14, 9.88 ]
Spector 2001 17 3.1 (7.04) 10 0 (7.04) 1.2 % 3.10 [ -2.40, 8.60 ]
Spector 2003 97 0.9 (3.5) 70 -0.4 (3.5) 32.5 % 1.30 [ 0.22, 2.38 ]
Subtotal (95% CI) 345 255 100.0 % 1.74 [ 1.13, 2.36 ]
Heterogeneity: Chi2 = 7.48, df = 9 (P = 0.59); I2 =0.0%
Test for overall effect: Z = 5.57 (P < 0.00001)
2 24 months of CS
Requena 2006 14 -1.31 (10.3) 15 -7.3 (10.5) 100.0 % 5.99 [ -1.58, 13.56 ]
Subtotal (95% CI) 14 15 100.0 % 5.99 [ -1.58, 13.56 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.55 (P = 0.12)
Test for subgroup differences: Chi2 = 1.20, df = 1 (P = 0.27), I2 =17%
-20 -10 0 10 20
Favours control Favours CS
55Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.3. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 3 ADAS-Cog.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 3 ADAS-Cog
Study or subgroup Cognitive stimulation ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 One to twelve months of CS
Bottino 2005 6 2.17 (8.33) 7 -0.43 (8.92) 1.9 % 2.60 [ -6.79, 11.99 ]
Buschert 2011 8 0.7 (8) 7 0 (6.93) 2.9 % 0.70 [ -6.86, 8.26 ]
Coen 2011 13 0.2 (7.2) 12 2.3 (4.1) 7.9 % -2.10 [ -6.65, 2.45 ]
Onder 2005 70 0.4 (6.69) 67 -2.5 (6.55) 33.3 % 2.90 [ 0.68, 5.12 ]
Requena 2006 20 6.4 (14.06) 30 -6.6 (20.48) 1.8 % 13.00 [ 3.43, 22.57 ]
Spector 2001 17 4.3 (17.33) 10 -1 (20.5) 0.7 % 5.30 [ -9.84, 20.44 ]
Spector 2003 97 1.9 (6.2) 70 -0.3 (5.5) 51.5 % 2.20 [ 0.42, 3.98 ]
Subtotal (95% CI) 231 203 100.0 % 2.27 [ 0.99, 3.55 ]
Heterogeneity: Chi2 = 9.01, df = 6 (P = 0.17); I2 =33%
Test for overall effect: Z = 3.48 (P = 0.00050)
2 24 months of CS
Requena 2006 14 3.38 (18.26) 15 -8.56 (17.13) 100.0 % 11.94 [ -0.97, 24.85 ]
Subtotal (95% CI) 14 15 100.0 % 11.94 [ -0.97, 24.85 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.81 (P = 0.070)
Test for subgroup differences: Chi2 = 2.13, df = 1 (P = 0.14), I2 =53%
-20 -10 0 10 20
Favours control Favours CS
56Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.4. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 4 Other cognitive measure: Information/Orientation.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 4 Other cognitive measure: Information/Orientation
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 CAPE I/O
Baines 1987 5 1.4 (4.59) 5 0.1 (6.4) 13.3 % 0.21 [ -1.03, 1.46 ]
Ferrario 1991 13 1.23 (3.64) 6 0 (2.93) 21.7 % 0.34 [ -0.63, 1.32 ]
Subtotal (95% CI) 18 11 35.0 % 0.29 [ -0.48, 1.06 ]
Heterogeneity: Chi2 = 0.03, df = 1 (P = 0.87); I2 =0.0%
Test for overall effect: Z = 0.74 (P = 0.46)
2 RCP Cognition
Wallis 1983 10 5.9 (35.5) 9 1.7 (27.04) 25.3 % 0.13 [ -0.78, 1.03 ]
Subtotal (95% CI) 10 9 25.3 % 0.13 [ -0.78, 1.03 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.27 (P = 0.78)
3 Berg Orientation Scale
Baldelli 1993a 13 2.6 (3.47) 10 -0.8 (4.1) 27.2 % 0.87 [ 0.00, 1.74 ]
Subtotal (95% CI) 13 10 27.2 % 0.87 [ 0.00, 1.74 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.97 (P = 0.049)
4 Information / Orientation
Woods 1979 5 4 (6.11) 5 0.1 (5.52) 12.5 % 0.60 [ -0.68, 1.89 ]
Subtotal (95% CI) 5 5 12.5 % 0.60 [ -0.68, 1.89 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.92 (P = 0.36)
Total (95% CI) 46 35 100.0 % 0.45 [ -0.01, 0.90 ]
Heterogeneity: Chi2 = 1.65, df = 4 (P = 0.80); I2 =0.0%
Test for overall effect: Z = 1.93 (P = 0.054)
Test for subgroup differences: Chi2 = 1.62, df = 3 (P = 0.65), I2 =0.0%
-4 -2 0 2 4
Favours control Favours CS
57Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.5. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 5 Comunication and social interaction.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 5 Comunication and social interaction
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Holden Communication Scale
Baines 1987 5 2 (7.56) 5 -2.6 (12.5) 4.7 % 0.40 [ -0.86, 1.66 ]
Spector 2001 17 -0.7 (10.5) 10 -0.5 (9.4) 12.1 % -0.02 [ -0.80, 0.76 ]
Spector 2003 97 0.2 (6.1) 70 -3.2 (6.3) 75.4 % 0.55 [ 0.23, 0.86 ]
Subtotal (95% CI) 119 85 92.1 % 0.47 [ 0.18, 0.75 ]
Heterogeneity: Chi2 = 1.75, df = 2 (P = 0.42); I2 =0.0%
Test for overall effect: Z = 3.22 (P = 0.0013)
2 MOSES - Withdrawn behaviour
Ferrario 1991 13 1.31 (6.31) 6 0.5 (9.44) 7.9 % 0.10 [ -0.86, 1.07 ]
Subtotal (95% CI) 13 6 7.9 % 0.10 [ -0.86, 1.07 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.21 (P = 0.83)
Total (95% CI) 132 91 100.0 % 0.44 [ 0.17, 0.71 ]
Heterogeneity: Chi2 = 2.24, df = 3 (P = 0.52); I2 =0.0%
Test for overall effect: Z = 3.15 (P = 0.0016)
Test for subgroup differences: Chi2 = 0.49, df = 1 (P = 0.48), I2 =0.0%
-10 -5 0 5 10
Favours control Favours CS
58Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.6. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 6 Well-being & Quality of Life.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 6 Well-being % Quality of Life
Study or subgroup Cognitive Stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Life Satisfaction Index
Baines 1987 5 -1.2 (6.09) 5 0.2 (4.64) 4.7 % -0.23 [ -1.48, 1.01 ]
Subtotal (95% CI) 5 5 4.7 % -0.23 [ -1.48, 1.01 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.37 (P = 0.71)
2 QoL-AD
Buschert 2011 8 -0.4 (10.61) 7 -0.9 (5.52) 7.1 % 0.05 [ -0.96, 1.07 ]
Coen 2011 14 3.6 (3.7) 13 0.5 (4.4) 11.9 % 0.74 [ -0.04, 1.53 ]
Spector 2003 97 1.3 (5.1) 70 -0.8 (5.6) 76.2 % 0.39 [ 0.08, 0.70 ]
Subtotal (95% CI) 119 90 95.3 % 0.41 [ 0.13, 0.69 ]
Heterogeneity: Chi2 = 1.17, df = 2 (P = 0.56); I2 =0.0%
Test for overall effect: Z = 2.91 (P = 0.0037)
Total (95% CI) 124 95 100.0 % 0.38 [ 0.11, 0.65 ]
Heterogeneity: Chi2 = 2.15, df = 3 (P = 0.54); I2 =0.0%
Test for overall effect: Z = 2.76 (P = 0.0058)
Test for subgroup differences: Chi2 = 0.98, df = 1 (P = 0.32), I2 =0.0%
-2 -1 0 1 2
Favours control Favours CS
59Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.7. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 7 Mood: Self-reported.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 7 Mood: Self-reported
Study or subgroup Cognitive Stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Geriatric Depression Scale (GDS-30) One to twelve months of CS
Baldelli 1993a 13 2.1 (4.61) 10 -2.3 (4.99) 12.7 % 0.89 [ 0.02, 1.76 ]
Baldelli 2002 71 3.21 (7.98) 16 2.57 (10) 32.7 % 0.08 [ -0.47, 0.62 ]
Requena 2006 20 5.6 (7.87) 30 2.03 (9.07) 29.4 % 0.41 [ -0.16, 0.98 ]
Subtotal (95% CI) 104 56 74.8 % 0.34 [ -0.01, 0.70 ]
Heterogeneity: Chi2 = 2.48, df = 2 (P = 0.29); I2 =19%
Test for overall effect: Z = 1.88 (P = 0.060)
2 Geriatric Depression Scale (14 item) One to twelve months of CS
Coen 2011 13 -0.9 (3) 13 0.1 (1.9) 15.9 % -0.39 [ -1.16, 0.39 ]
Subtotal (95% CI) 13 13 15.9 % -0.39 [ -1.16, 0.39 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.97 (P = 0.33)
3 Montgomery Asberg Depression Rating Scale (MADRS) One to twelve months of CS
Buschert 2011 8 1.5 (5.33) 7 -0.4 (6.4) 9.2 % 0.31 [ -0.72, 1.33 ]
Subtotal (95% CI) 8 7 9.2 % 0.31 [ -0.72, 1.33 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.59 (P = 0.56)
Total (95% CI) 125 76 100.0 % 0.22 [ -0.09, 0.53 ]
Heterogeneity: Chi2 = 5.30, df = 4 (P = 0.26); I2 =25%
Test for overall effect: Z = 1.42 (P = 0.16)
Test for subgroup differences: Chi2 = 2.82, df = 2 (P = 0.24), I2 =29%
-2 -1 0 1 2
Favours control Favours CS
60Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.8. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 8 Mood: Staff-reported.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 8 Mood: Staff-reported
Study or subgroup Cognitive Stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Cornell Scale for Depression in Dementia
Spector 2001 17 2.6 (8.05) 10 -2.2 (7.19) 10.5 % 0.60 [ -0.20, 1.40 ]
Spector 2003 97 0 (6.2) 70 0.5 (7) 71.2 % -0.08 [ -0.38, 0.23 ]
Subtotal (95% CI) 114 80 81.7 % 0.01 [ -0.28, 0.30 ]
Heterogeneity: Chi2 = 2.39, df = 1 (P = 0.12); I2 =58%
Test for overall effect: Z = 0.08 (P = 0.94)
2 MOSES - Depressed / anxious mood
Ferrario 1991 13 1.08 (9.5) 6 1.17 (4.62) 7.2 % -0.01 [ -0.98, 0.96 ]
Subtotal (95% CI) 13 6 7.2 % -0.01 [ -0.98, 0.96 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.02 (P = 0.98)
3 Rating of Anxiety in Dementia (RAID)
Coen 2011 14 1.1 (7.3) 12 -1.6 (6.4) 11.1 % 0.38 [ -0.40, 1.16 ]
Subtotal (95% CI) 14 12 11.1 % 0.38 [ -0.40, 1.16 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.95 (P = 0.34)
Total (95% CI) 141 98 100.0 % 0.05 [ -0.21, 0.31 ]
Heterogeneity: Chi2 = 3.16, df = 3 (P = 0.37); I2 =5%
Test for overall effect: Z = 0.38 (P = 0.70)
Test for subgroup differences: Chi2 = 0.77, df = 2 (P = 0.68), I2 =0.0%
-2 -1 0 1 2
Favours control Favours CS
61Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.9. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 9 ADL scales.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 9 ADL scales
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Baldelli 1993a 13 1.5 (39.47) 10 -8.9 (39.2) 10.0 % 0.25 [ -0.57, 1.08 ]
Baldelli 2002 71 15.37 (34.94) 16 11.88 (40.48) 23.4 % 0.10 [ -0.45, 0.64 ]
Bottino 2005 6 1 (3.27) 7 0.15 (2.86) 5.7 % 0.26 [ -0.84, 1.36 ]
Onder 2005 70 -0.9 (8.37) 67 -2.9 (8.19) 60.9 % 0.24 [ -0.10, 0.58 ]
Total (95% CI) 160 100 100.0 % 0.21 [ -0.05, 0.47 ]
Heterogeneity: Chi2 = 0.22, df = 3 (P = 0.97); I2 =0.0%
Test for overall effect: Z = 1.56 (P = 0.12)
Test for subgroup differences: Not applicable
-1 -0.5 0 0.5 1
Favours control Favours CS
62Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.10. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 10 Behaviour, general.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 10 Behaviour, general
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 CAPE - BRS
Baines 1987 5 4.8 (3.87) 5 -1.2 (9.37) 2.2 % 0.76 [ -0.55, 2.07 ]
Coen 2011 14 0 (3.6) 13 -1.4 (5.4) 6.6 % 0.30 [ -0.46, 1.06 ]
Spector 2001 17 -1.1 (6.08) 10 -0.6 (7.07) 6.2 % -0.08 [ -0.86, 0.71 ]
Spector 2003 97 -0.2 (6.1) 70 -0.7 (5.5) 40.2 % 0.08 [ -0.22, 0.39 ]
Subtotal (95% CI) 133 98 55.3 % 0.12 [ -0.14, 0.38 ]
Heterogeneity: Chi2 = 1.41, df = 3 (P = 0.70); I2 =0.0%
Test for overall effect: Z = 0.89 (P = 0.37)
2 Crichton BRS (modified)
Wallis 1983 10 -0.3 (24.92) 9 -2.4 (21.28) 4.7 % 0.09 [ -0.81, 0.99 ]
Woods 1979 5 -1 (5.06) 5 -5.2 (3.82) 2.2 % 0.85 [ -0.48, 2.17 ]
Subtotal (95% CI) 15 14 6.8 % 0.33 [ -0.42, 1.07 ]
Heterogeneity: Chi2 = 0.86, df = 1 (P = 0.35); I2 =0.0%
Test for overall effect: Z = 0.86 (P = 0.39)
3 MOSES Self-care
Ferrario 1991 13 -0.31 (9.88) 6 -0.33 (5.89) 4.1 % 0.00 [ -0.97, 0.97 ]
Subtotal (95% CI) 13 6 4.1 % 0.00 [ -0.97, 0.97 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.00 (P = 1.0)
4 Instrumental ADL
Onder 2005 70 0 (1.67) 67 -0.2 (1.64) 33.8 % 0.12 [ -0.22, 0.46 ]
Subtotal (95% CI) 70 67 33.8 % 0.12 [ -0.22, 0.46 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.70 (P = 0.48)
Total (95% CI) 231 185 100.0 % 0.13 [ -0.07, 0.32 ]
Heterogeneity: Chi2 = 2.61, df = 7 (P = 0.92); I2 =0.0%
Test for overall effect: Z = 1.30 (P = 0.20)
Test for subgroup differences: Chi2 = 0.34, df = 3 (P = 0.95), I2 =0.0%
-2 -1 0 1 2
Favours control Favours CS
63Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.11. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 11 Behaviour, problem.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 11 Behaviour, problem
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Problem Behaviour Rating Scale
Baines 1987 5 3.6 (11.4) 5 -1.8 (12.8) 6.0 % 0.40 [ -0.86, 1.66 ]
Subtotal (95% CI) 5 5 6.0 % 0.40 [ -0.86, 1.66 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.63 (P = 0.53)
2 MOSES - Irritable
Ferrario 1991 13 0.69 (2.45) 6 0.16 (6.89) 10.1 % 0.12 [ -0.85, 1.09 ]
Subtotal (95% CI) 13 6 10.1 % 0.12 [ -0.85, 1.09 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.24 (P = 0.81)
3 NPI
Onder 2005 70 -0.9 (15.9) 67 2.5 (17.19) 83.9 % -0.20 [ -0.54, 0.13 ]
Subtotal (95% CI) 70 67 83.9 % -0.20 [ -0.54, 0.13 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.19 (P = 0.23)
Total (95% CI) 88 78 100.0 % -0.14 [ -0.44, 0.17 ]
Heterogeneity: Chi2 = 1.13, df = 2 (P = 0.57); I2 =0.0%
Test for overall effect: Z = 0.86 (P = 0.39)
Test for subgroup differences: Chi2 = 1.13, df = 2 (P = 0.57), I2 =0.0%
-4 -2 0 2 4
Favours control Favours CS
64Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.12. Comparison 1 Cognitive stimulation versus no cognitive stimulation: post-treatment,
Outcome 12 Caregiver outcome.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome: 12 Caregiver outcome
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Hamilton anxiety
Bottino 2005 6 4.83 (6.33) 7 0.14 (5.41) 7.9 % 0.75 [ -0.40, 1.89 ]
Onder 2005 70 -0.3 (3.35) 67 -0.5 (3.27) 92.1 % 0.06 [ -0.27, 0.40 ]
Subtotal (95% CI) 76 74 100.0 % 0.11 [ -0.21, 0.44 ]
Heterogeneity: Chi2 = 1.27, df = 1 (P = 0.26); I2 =22%
Test for overall effect: Z = 0.70 (P = 0.49)
2 Depression
Bottino 2005 6 3.83 (7.71) 7 2.29 (7.69) 8.6 % 0.19 [ -0.91, 1.28 ]
Onder 2005 70 -0.9 (3.35) 67 -1 (3.27) 91.4 % 0.03 [ -0.30, 0.37 ]
Subtotal (95% CI) 76 74 100.0 % 0.04 [ -0.28, 0.36 ]
Heterogeneity: Chi2 = 0.07, df = 1 (P = 0.79); I2 =0.0%
Test for overall effect: Z = 0.27 (P = 0.79)
3 Carer stress/burden
Onder 2005 70 -2 (11.7) 67 -1.3 (12.3) 93.3 % -0.06 [ -0.39, 0.28 ]
Spector 2001 5 -1 (12.8) 5 -9 (26.6) 6.7 % 0.35 [ -0.91, 1.60 ]
Subtotal (95% CI) 75 72 100.0 % -0.03 [ -0.35, 0.29 ]
Heterogeneity: Chi2 = 0.37, df = 1 (P = 0.54); I2 =0.0%
Test for overall effect: Z = 0.19 (P = 0.85)
4 General Health Questionnaire (GHQ-12)
Spector 2001 5 3.8 (2.91) 5 -0.3 (4.75) 100.0 % 0.94 [ -0.41, 2.29 ]
Subtotal (95% CI) 5 5 100.0 % 0.94 [ -0.41, 2.29 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.37 (P = 0.17)
Test for subgroup differences: Chi2 = 2.06, df = 3 (P = 0.56), I2 =0.0%
-2 -1 0 1 2
Favours control Favours CS
65Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.1. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 1
Cognition.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 2 Cognitive stimulation versus no cognitive stimulation: follow-up
Outcome: 1 Cognition
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 One to three months follow-up Information/ Orientation
Baines 1987 5 -0.2 (4.46) 5 -2.3 (5.94) 20.0 % 0.36 [ -0.90, 1.62 ]
Baldelli 1993a 13 1.4 (3.75) 10 -2 (3.96) 41.9 % 0.85 [ -0.01, 1.72 ]
Wallis 1983 10 8.5 (36.6) 9 -4.9 (30.7) 38.1 % 0.38 [ -0.53, 1.29 ]
Subtotal (95% CI) 28 24 100.0 % 0.57 [ 0.01, 1.14 ]
Heterogeneity: Chi2 = 0.69, df = 2 (P = 0.71); I2 =0.0%
Test for overall effect: Z = 2.00 (P = 0.045)
2 Ten months follow-up MMSE
Chapman 2004 26 -1.25 (3.98) 28 -2.14 (5.51) 100.0 % 0.18 [ -0.35, 0.72 ]
Subtotal (95% CI) 26 28 100.0 % 0.18 [ -0.35, 0.72 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.66 (P = 0.51)
3 Ten months follow-up ADAS-Cog
Chapman 2004 26 -4.89 (5.78) 28 -5.62 (6.02) 100.0 % 0.12 [ -0.41, 0.66 ]
Subtotal (95% CI) 26 28 100.0 % 0.12 [ -0.41, 0.66 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.45 (P = 0.66)
Test for subgroup differences: Chi2 = 1.51, df = 2 (P = 0.47), I2 =0.0%
-2 -1 0 1 2
Favours control Favours CS
66Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.2. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 2
Well-being & Quality of Life.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 2 Cognitive stimulation versus no cognitive stimulation: follow-up
Outcome: 2 Well-being % Quality of Life
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 One month follow-up Life Satisfaction Index
Baines 1987 5 -1.6 (3.85) 5 -1.4 (7.44) 100.0 % -0.03 [ -1.27, 1.21 ]
Subtotal (95% CI) 5 5 100.0 % -0.03 [ -1.27, 1.21 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.05 (P = 0.96)
2 Ten months follow-up QoL-AD
Chapman 2004 26 2.05 (5.98) 28 -0.1 (6.29) 100.0 % 0.34 [ -0.19, 0.88 ]
Subtotal (95% CI) 26 28 100.0 % 0.34 [ -0.19, 0.88 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.26 (P = 0.21)
Test for subgroup differences: Chi2 = 0.30, df = 1 (P = 0.59), I2 =0.0%
-4 -2 0 2 4
Favours control Favours CS
67Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.3. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 3
Behaviour, general.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 2 Cognitive stimulation versus no cognitive stimulation: follow-up
Outcome: 3 Behaviour, general
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 One month follow-up
Baines 1987 5 3.5 (5.21) 5 0 (5.51) 33.5 % 0.59 [ -0.69, 1.87 ]
Wallis 1983 10 5.9 (28.15) 9 -3.7 (20.83) 66.5 % 0.37 [ -0.54, 1.28 ]
Subtotal (95% CI) 15 14 100.0 % 0.44 [ -0.30, 1.18 ]
Heterogeneity: Chi2 = 0.08, df = 1 (P = 0.78); I2 =0.0%
Test for overall effect: Z = 1.17 (P = 0.24)
2 Ten months follow-up Texas Functional Living Scale
Chapman 2004 26 -2.89 (7.21) 28 -6.86 (10.42) 100.0 % 0.43 [ -0.11, 0.97 ]
Subtotal (95% CI) 26 28 100.0 % 0.43 [ -0.11, 0.97 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.57 (P = 0.12)
Test for subgroup differences: Chi2 = 0.00, df = 1 (P = 0.99), I2 =0.0%
-4 -2 0 2 4
Favours control Favours CS
68Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.4. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 4
Behaviour, problem.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 2 Cognitive stimulation versus no cognitive stimulation: follow-up
Outcome: 4 Behaviour, problem
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 One month follow-up Problem Behaviour Rating Scale
Baines 1987 5 5 (10.88) 5 0.2 (11.12) 100.0 % 0.39 [ -0.87, 1.65 ]
Subtotal (95% CI) 5 5 100.0 % 0.39 [ -0.87, 1.65 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.61 (P = 0.54)
2 Ten month follow-up NPI severity
Chapman 2004 26 2.25 (14.33) 28 -2.19 (15.33) 100.0 % 0.29 [ -0.24, 0.83 ]
Subtotal (95% CI) 26 28 100.0 % 0.29 [ -0.24, 0.83 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.08 (P = 0.28)
3 Ten-month follow up NPI (Caregiver Distress)
Chapman 2004 26 1.35 (6.19) 28 -2.1 (9.86) 100.0 % 0.41 [ -0.13, 0.95 ]
Subtotal (95% CI) 26 28 100.0 % 0.41 [ -0.13, 0.95 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.49 (P = 0.14)
Test for subgroup differences: Chi2 = 0.09, df = 2 (P = 0.96), I2 =0.0%
-4 -2 0 2 4
Favours control Favours CS
69Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.5. Comparison 2 Cognitive stimulation versus no cognitive stimulation: follow-up, Outcome 5
Communication and social interaction.
Review: Cognitive stimulation to improve cognitive functioning in people with dementia
Comparison: 2 Cognitive stimulation versus no cognitive stimulation: follow-up
Outcome: 5 Communication and social interaction
Study or subgroup Cognitive stimulation Control
Std.Mean
Difference Weight
Std.Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 One month follow-up Holden Communication Scale
Baines 1987 5 3.4 (6.43) 5 1.2 (12.81) 100.0 % 0.20 [ -1.05, 1.44 ]
Subtotal (95% CI) 5 5 100.0 % 0.20 [ -1.05, 1.44 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.31 (P = 0.76)
2 Ten month follow-up ’Relevance of discourse’
Chapman 2004 26 -3.35 (11.11) 28 -5.05 (11.85) 100.0 % 0.15 [ -0.39, 0.68 ]
Subtotal (95% CI) 26 28 100.0 % 0.15 [ -0.39, 0.68 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.53 (P = 0.59)
Test for subgroup differences: Chi2 = 0.01, df = 1 (P = 0.94), I2 =0.0%
-4 -2 0 2 4
Favours control Favours CS
A P P E N D I C E S
Appendix 1. Search: December 2011
Source Search strategy Hits retrieved
1. ALOIS (www.medicine.ox.ac.uk/alois)
(all dates)
cognitive stimulation OR reality orienta-
tion OR memory therapy OR memory
groups OR memory support OR mem-
ory stimulation OR global stimulation OR
cognitive psychostimulation
139
70Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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(Continued)
2. MEDLINE In-process and other non-
indexed citations and MEDLINE 1950-
present (Ovid SP)
1. exp Dementia/
2. Delirium/
3. Wernicke Encephalopathy/
4. Delirium, Dementia, Amnestic, Cogni-
tive Disorders/
5. dement*.mp.
6. alzheimer*.mp.
7. (lewy* adj2 bod*).mp.
8. deliri*.mp.
9. (chronic adj2 cerebrovascular).mp.
10. (“organic brain disease” or “organic
brain syndrome”).mp
11. (“normal pressure hydrocephalus” and
“shunt*”).mp.
12. “benign senescent forgetfulness”.mp.
13. (cerebr* adj2 deteriorat*).mp.
14. (cerebral* adj2 insufficient*).mp.
15. (pick* adj2 disease).mp.
16. (creutzfeldt or jcd or cjd).mp.
17. huntington*.mp.
18. binswanger*.mp.
19. korsako*.mp.
20. or/1-19
21. “cognitiv* stimul*”.mp.
22. “reality orientation”.mp.
23. (memory adj2 therapy).mp.
24. “memory group*”.mp.
25. “memory support”.mp.
26. (memory adj2 stimulat*).mp.
27. “global stimulation”.mp.
28. (“cognitive psycho-stimulation” or
“cognitive psychostimulation”).mp
29. *Psychomotor Performance/
30. or/21-29
31. 20 and 30
32. (2010* OR 2011*).ed.
33. 31 and 32
34. randomized controlled trial.pt.
35. controlled clinical trial.pt.
36. randomized.ab.
37. placebo.ab.
38. drug therapy.fs.
39. randomly.ab.
40. trial.ab.
41. groups.ab.
42. or/34-41
43. (animals not (humans and animals)).
40
71Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
sh.
44. 42 not 43
45. 33 and 44
3. EMBASE
1980-2011 Dec 05 (Ovid SP)
1. exp dementia/
2. Lewy body/
3. delirium/
4. Wernicke encephalopathy/
5. cognitive defect/
6. dement*.mp.
7. alzheimer*.mp.
8. (lewy* adj2 bod*).mp.
9. deliri*.mp.
10. (chronic adj2 cerebrovascular).mp.
11. (“organic brain disease” or “organic
brain syndrome”).mp
12. “supranuclear palsy”.mp.
13. (“normal pressure hydrocephalus” and
“shunt*”).mp.
14. “benign senescent forgetfulness”.mp.
15. (cerebr* adj2 deteriorat*).mp.
16. (cerebral* adj2 insufficient*).mp.
17. (pick* adj2 disease).mp.
18. (creutzfeldt or jcd or cjd).mp.
19. huntington*.mp.
20. binswanger*.mp.
21. korsako*.mp.
22. CADASIL.mp.
23. or/1-22
24. “cognitiv* stimul*”.mp.
25. “reality orientation”.mp.
26. (memory adj2 therapy).mp.
27. “memory group*”.mp.
28. “memory support”.mp.
29. (memory adj2 stimulat*).mp.
30. “global stimulation”.mp.
31. (“cognitive psycho-stimulation” or
“cognitive psychostimulation”).mp
32. *psychomotor performance/
33. or/24-32
34. 23 and 33
35. (2010* OR 2011*).em.
36. 34 and 35
239
4. PsycINFO
1806-November week 5 2011 (Ovid SP)
1. exp Dementia/
2. exp Delirium/
3. exp Huntingtons Disease/
4. exp Kluver Bucy Syndrome/
5. exp Wernickes Syndrome/
6. exp Cognitive Impairment/
29
72Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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(Continued)
7. dement*.mp.
8. alzheimer*.mp.
9. (lewy* adj2 bod*).mp.
10. deliri*.mp.
11. (chronic adj2 cerebrovascular).mp.
12. (“organic brain disease” or “organic
brain syndrome”).mp
13. “supranuclear palsy”.mp.
14. (“normal pressure hydrocephalus” and
“shunt*”).mp.
15. “benign senescent forgetfulness”.mp.
16. (cerebr* adj2 deteriorat*).mp.
17. (cerebral* adj2 insufficient*).mp.
18. (pick* adj2 disease).mp.
19. (creutzfeldt or jcd or cjd).mp.
20. huntington*.mp.
21. binswanger*.mp.
22. korsako*.mp.
23. (“parkinson* disease dementia” or PDD
or “parkinson* dementia”).mp
24. or/1-23
25. “cognitiv* stimul*”.mp.
26. “reality orientation”.mp.
27. (memory adj2 therapy).mp.
28. “memory group*”.mp.
29. “memory support”.mp.
30. (memory adj2 stimulat*).mp.
31. “global stimulation”.mp.
32. (“cognitive psycho-stimulation” or
“cognitive psychostimulation”).mp
33. “psychomotor performance”.mp.
34. or/25-33
35. 24 and 34
36. random*.mp.
37. trial.mp.
38. placebo.mp.
39. group*.mp.
40. exp Clinical Trials/
41. or/36-40
42. 35 and 41
43. (2010* OR 2011*).up.
44. 42 and 43
5. CINAHL (EBSCOhost) S1 (MH “Dementia+”)
S2 (MH “Delirium”) or (MH “Delir-
ium, Dementia, Amnestic, Cognitive Dis-
orders”)
S3 (MH “Wernicke’s Encephalopathy”)
S4 TX dement*
S5 TX alzheimer*
34
73Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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(Continued)
S6 TX lewy* N2 bod*
S7 TX deliri*
S8 TX chronic N2 cerebrovascular
S9 TX “organic brain disease” or “organic
brain syndrome”
S10 TX “normal pressure hydrocephalus”
and “shunt*”
S11 TX “benign senescent forgetfulness”
S12 TX cerebr* N2 deteriorat*
S13 TX cerebral* N2 insufficient*
S14 TX pick* N2 disease
S15 TX creutzfeldt or jcd or cjd
S16 TX huntington*
S17 TX binswanger*
S18 TX korsako*
S19 S1 or S2 or S3 or S4 or S5 or S6 or S7
or S8 or S9 or S10 or S11 or S12 or S13 or
S14 or S15 or S16 or S17 or S18
S20 TX “cognitiv* stimul*”
S21 TX “reality orientation”
S22 TX memory N2 therapy
S23 TX “memory group*”
S24 TX “memory support”
S25 TX memory N2 stimulat*
S26 TX “global stimulation”
S27 TX “cognitive psycho-stimulation”
OR “cognitive psychostimulation”
S28 (MM “Psychomotor Performance”)
S29 S20 or S21 or S22 or S23 or S24 or
S25 or S26 or S27 or S28
S30 S19 and S29
S31 EM 2010
S32 EM 2011
S33 S31 or S32
S34 S30 and S33
S35 TX random*
S36 (MH “Clinical Trials+”)
S37 AB group
S38 TI study
S39 S35 or S36 or S37 or S38
S40 S34 and S39
6. Web of Science (1945-present) (WOK) Topic=(dement* OR alzheimer* OR “lew*
bod*” OR deliri* OR creutzfeldt OR cjd
OR jcd OR huntington* OR binswanger*
OR korsako*) AND Topic=(“cognitiv*
stimul*” OR CST OR “reality orien-
ation” OR “memory therapy” OR “mem-
ory group*” OR “memory support” OR
135
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(Continued)
“psychomotor performance” OR “global
stimulation” OR “cognitive performance”)
AND Topic=(random* OR trial* OR RCT
OR “cross-over” OR cross-over) AND Year
Published=(2010-2011)
Timespan=All Years. Databases=
SCI-EXPANDED, SSCI, A&HCI, CPCI-
S, CPCI-SSH
Lemmatization=On
7. LILACS (BIREME) “cognitiv$ stimul$” OR “reality orien-
ation” OR “memory therapy” OR “mem-
ory group$” OR “memory support” OR
“psychomotor performance” OR “global
stimulation” OR “cognitive performance”
[Words] and dementia OR alzheimer$ OR
demenc$ OR AD OR demência [Words]
16
8. CENTRAL (The Cochrane Library) (Is-
sue 3 of 4, Oct 2011)
#1 dement*
#2 alzheimer*
#3 deliri*
#4 chronic adj2 cerebrovascular
#5 (lewy* bod*)
#6 “organic brain disease” or “organic brain
syndrome”
#7 (pick* disease)
#8 creutzfeldt or jcd or cjd
#9 huntington*
#10 binswanger*
#11 korsako*
#12 (#1 OR #2 OR #3 OR #4 OR #5 OR
#6 OR #7 OR #8 OR #9 OR #10 OR #
11)
#13 “cognitiv* stimul*”
#14 “reality orientation”
#15 “memory therapy”
#16 “memory group*”
#17 “memory support”
#18 “memory stimulat*”
#19 “global stimulation”
#20 “cognitive psycho-stimulation”
#21 “cognitive psychostimulation”
#22 MeSH descriptor Psychomotor Perfor-
mance explode all trees
#23 (#13 OR #14 OR #15 OR #16 OR #
17 OR #18 OR #19 OR #20 OR #21 OR
#22)
#24 (#12 AND #23)
35
75Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
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(Continued)
#25 (#24), from 2010 to 2011
9. Clinicaltrials.gov (
www.clinicaltrials.gov)
#1 Intervention: Cognitive stimulation
AND Interventional studies AND First rec:
01/01/2010-12/05/2011 = 30
#2 Intervention: reality orientation AND
Interventional studies AND First rec: 01/
01/2010-12/05/2011 = 1
#3 Interventional Studies | dementia OR
alzheimers OR AD OR alzheimer’s OR
alzheimer OR lewy OR FTLD OR FLD
| memory therapy OR memory training |
received from 01/01/2010 to 12/05/2011=
20
51
10. ICTRP Search Portal (http:/
/apps.who.int/trialsearch) [includes: Aus-
tralian New Zealand Clinical Trials Reg-
istry; ClinicalTrilas.gov; ISRCTN; Chinese
Clinical Trial Registry; Clinical Trials Reg-
istry - India; Clinical Research Informa-
tion Service - Republic of Korea; German
Clinical Trials Register; Iranian Registry
of Clinical Trials; Japan Primary Registries
Network; Pan African Clinical Trial Reg-
istry; Sri Lanka Clinical Trials Registry; The
Netherlands National Trial Register]
Advanced search: (dementia OR alzheimer
OR alzheimers OR alzheimers) AND (cog-
nitive stimulation OR reality orientation
OR memory therapy OR memory training
OR cognitive training) AND (2010-2011)
86
TOTAL before de-duplication 804
TOTAL after de-dupe and first-assess 41
H I S T O R Y
Protocol first published: Issue 4, 2005
Review first published: Issue 2, 2012
76Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C O N T R I B U T I O N S O F A U T H O R S
BW: correspondence; drafting review versions; search for trials; selection of trials; extraction of data; entry of data; data analysis;
interpretation of data analyses; updating review.
AS: selection of trials; extraction of data; interpretation of data analyses; updating review.
EA: search for trials; obtaining copies of trial reports; entry of data; data analysis; interpretation of data analyses.
MO: selection of trials; extraction of data; interpretation of data analyses; updating review.
D E C L A R A T I O N S O F I N T E R E S T
The authors have produced various training materials in dementia care, including cognitive stimulation therapy manuals, in order to
disseminate research findings to care workers and others. Royalties for the manuals are received by the Dementia Services Development
Centre Wales. AS receives fees for providing training in cognitive stimulation approaches.
S O U R C E S O F S U P P O R T
Internal sources
• Bangor University, UK.
• University College London, UK.
External sources
• NIHR, UK.
EA was supported by the Support at Home - Interventions to Enhance Life in Dementia (SHIELD) project (Application No RP-PG-
0606-1083) which is funded by the NIHR Programme Grants for Applied Research funding scheme.
N O T E S
This review replaces the review of Reality Orientation for dementia (Spector A, Orrell M, Davies S, Woods B. Reality orientation for
dementia. The Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD001119. DOI: 10.1002/14651858.CD001119).
I N D E X T E R M S
Medical Subject Headings (MeSH)
Cognition [∗physiology]; Dementia [∗therapy]; Memory [physiology]; Orientation [∗physiology]; Psychotherapy [∗methods]; Ran-
domized Controlled Trials as Topic
77Cognitive stimulation to improve cognitive functioning in people with dementia (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.