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 Library
2012, 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.
 TABLE OF CONTENTS

HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
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
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Figure 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
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
Cognitive stimulation to improve cognitive functioning in people with dementia (Review) i
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
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) ii

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Cognitive stimulation to improve cognitive functioning in

people with dementia

Bob Woods1 , Elisa Aguirre2 , Aimee E Spector3 , Martin Orrell4

1 Dementia Services Development Centre Wales, Bangor University, Bangor, UK. 2 University College London,
London, UK. 3 Research
4
Department of Clinical, Educational and Health Psychology, University College, London, London, UK. Research 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.

ABSTRACT
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.
Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 1
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.

PLAIN LANGUAGE SUMMARY

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.

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 2

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
BACKGROUND
is not least of all because of the difficulty in monitoring its imple-
Interventions with a cognitive focus have long been used in de-
mentation, with informal interactions being much more difficult
mentia care. They have been developed in parallel with approaches
to document than a formal group meeting. Williams 1987 reports
emphasising the stimulation of the senses (Woods 1977). Reality
using a modified form of 24 hour RO where staff were trained to
Orientation (RO) (Taulbee 1966) was developed in the late 1950s
respond appropriately to residents’ requests for information, and
as a response to confusion and disorientation in older patients in
found that 90% of staff responses to residents’ requests complied
hospital units in the USA, and was the prototype of the cognitive with the treatment protocol. This study reported improvements
stimulation approach. Classes were held for 30 minutes once or
in cognition, independent functioning and orientation, compared
twice per day. Basic personal and current information was pre-
with a control group on a separate ward, when this form of 24
sented to the patient and a variety of materials used, such as in-
hour RO was implemented.
dividual calendars, word-letter games, building blocks and large-
piece puzzles. A Reality Orientation board would be used in each Alongside the RO literature, in recent years there has been increas-
session and would list the name of the unit and its location, the ing discussion of ’cognitive stimulation’. In part this reflects a gen-
day, date, weather, current events etc. The approach emphasised eral view that lack of cognitive activity hastens cognitive decline,
the engagement of nursing assistants in a hopeful, therapeutic pro- in normal ageing as well as in dementia (Breuil 1994; Small 2002),
cess. 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
The first controlled evaluation of RO was reported in the UK by
and respectful manner (Spector 2001; Woods 2002). There has
Brook et al (Brook 1975). They found positive benefits on ratings
also been growing interest in the application of various forms of
of intellectual and social functioning in patients attending RO
cognitive training and in teaching individual people with demen-
group sessions for 30 minutes per day, five days per week for four
tia to use memory aids and strategies to assist with their particular
months compared with a control group who visited a special RO
difficulties that have been identified with the person. A Cochrane
room daily but were not given any encouragement to engage with
review of cognitive training and cognitive rehabilitation in early
the materials or each other. A spate of controlled studies followed
stage dementia has been completed (Clare 2003) and it is impor-
(Holden 1995), with outcome measures typically including assess-
tant to ensure that clear definitions are used to avoid confusion
ments of orientation, other aspects of cognitive functioning and
between the various cognition-based approaches, as in the past
level of independent functioning. A Cochrane review specifically
’training’, ’stimulation’ and ’rehabilitation’ have been used almost
examining Reality Orientation (Spector 2000a; Spector 2000b)
interchangeably.
concluded that there was some evidence that RO had benefits for
people with dementia on both cognition and behaviour. How- Clare and Woods (Clare 2004) proposed the following definitions.
ever, outside of a few countries (notably Italy), RO has been little
practised or researched since 1990 and has attracted some crit- Cognitive stimulation is engagement in a range of activities and
icism (Burton 1982; Dietch 1989; Powell-Proctor 1982), espe- discussions (usually in a group) aimed at general enhancement of
cially for being applied in a mechanical, inflexible, insensitive and cognitive and social functioning.
confrontational manner. Doubts were also raised about the clin- Cognitive training is guided practice on a set of standard tasks
ical significance of any improvements; the person with dementia designed to reflect particular cognitive functions; a range of diffi-
might now know what day of the week it was but would this have culty levels may be available within the standard set of tasks to suit
any meaningful impact on the person’s life? Such was the concern the individual’s level of ability. It may be offered in individual or
regarding the insensitive use of RO and other cognitive approaches group sessions, with pencil and paper or computerised exercises.
that one influential set of guidelines on the management of de-
mentia (APA 1997) cautioned against their use with the possibility Cognitive rehabilitation is an individualised approach where per-
of a negative impact on the person’s well-being that outweighed sonally relevant goals are identified and the therapist works with
any small cognitive improvements. the person and his or her family to devise strategies to address
these. The emphasis is on improving performance in everyday life
In addition to the ’classroom’ element of RO, from the early days
rather than on cognitive tests, building on the person’s strengths
’24 hour RO’ was also advocated. This involves staff taking every
and developing ways of compensating for impairments
opportunity to provide current information to the person, outside
of the formal setting of the RO group, as well as using environ- Using these definitions, this review included studies on RO group
mental features such as sign-posting and orientation boards to as- sessions but not on 24 hour RO or direct training in spatial orien-
sist orientation. There have been some positive evaluations of the tation. The primary outcomes examined will be in relation to the
effects of training and sign-posting on orientation around a care person’s cognitive functioning. It is considered that this is the min-
facility (for example Hanley 1981; McGilton 2003) but the effects imum expectation of a general approach with this focus. However,
of 24 hour RO per se have been more difficult to evaluate. This given the concerns discussed above of a possible negative effect,

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
measures of quality of life, mood and well-being are highly per- (Folstein 1975) or Clinical Dementia Rating (CDR) (Hughes
tinent secondary outcome measures. The effects on the person’s 1982). All levels of severity were included.
general level of function in everyday life also need to be considered • Qualifying participants received the intervention in a range
in evaluating the meaning of any changes observed for the individ- of settings, including their own home, as outpatients and in day-
ual and his or her supporters. The impact on family caregivers and care and residential settings.
careworkers is also important to consider as they are key partners • No specific restrictions regarding age were applied.
in the process of care. • 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
OBJECTIVES were co-resident.
• The number of participants receiving concurrent treatment
• To evaluate the effectiveness and impact of cognitive with acetylcholinesterase inhibitors was documented, where
stimulation interventions aimed at improving cognition for possible.
people with dementia, including any negative effects.
• To indicate the nature and quality of the evidence available Types of interventions
on this topic.
• Studies were considered for this review if they described a
• To assist in establishing the appropriateness of offering cognitive stimulation intervention targeting cognitive and social
cognitive stimulation interventions to people with dementia and functioning. These interventions may also have been described as
identifying the factors associated with their efficacy. 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
METHODS
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
Criteria for considering studies for this review 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
Types of studies was understood to be the treatment that was normally provided
This review focused on randomised controlled trials (RCTs) for to patients with dementia in the study setting and could include
which adequate information was provided or could be obtained provision of medication, clinic consultations, contact with a
from the researchers. The studies included must have been pub- community mental health team, day care, or support from
lished, written in English and presented in a peer-reviewed journal voluntary organisations. Placebo conditions could consist, for
article. 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
Types of participants study was one month. There were no restrictions on the number
• Participants with a diagnosis of dementia. The main of treatment sessions, although this was noted.
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 Types of outcome measures
studies, included from the previous review of RO, used other • Outcomes were considered in relation to the impact of the
terms for this population but were included where the review intervention on the person with dementia and on the primary
authors were satisfied that the included population would now family caregiver. Studies could present data in both these
be described as having a dementia. Participants with mild categories.
cognitive impairment, where the extent of cognitive impairment • Short term (immediately after the intervention) and
or its effects on day-to-day function were insufficient to justify a medium term (follow-up one month to one year after the
dementia diagnosis, were not included. intervention finished) outcomes were considered.
• Severity of dementia was indicated through group mean • Outcomes for the person with dementia and the caregiver
scores, range of scores, or individual scores on a standardised were considered where these were assessed using scores on
scale such as the Mini-Mental State Examination (MMSE) standardised tests, rating scales and questionnaires.

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 • Rates of attrition and reasons for participants dropping out 2. monthly searches of a number of trial registers: meta
from the study were noted. Register of Controlled Trials; Umin Japan Trial Register; WHO
portal (which covers ClinicalTrials.gov; ISRCTN; Chinese
Clinical Trials Register; German Clinical Trials Register; Iranian
Outcomes for the person with dementia Registry of Clinical Trials and the Netherlands National Trials
Outcome measures for the person with dementia sought to identify Register, plus others);
whether changes were observed following the intervention. The 3. quarterly search of the Cochrane Central Register of
following variables were considered as outcome measures for the Controlled Trials (CENTRAL) (The Cochrane Library);
person with dementia. 4. six-monthly searches of a number of grey literature sources:
• Performance on at least one test of cognitive functioning ISI Web of Knowledge Conference Proceedings; Index to
(including tests of memory and orientation). Theses; Australasian Digital Theses.
To view a list of all sources searched for ALOIS see About ALOIS
• Self-reported, clinically-rated or carer-reported measures for on the ALOIS website.
mood of the person with dementia. Details of the search strategies used for the retrieval of reports of
• Self-reported or carer-reported quality of life or well-being trials from the healthcare databases, CENTRAL and conference
measures for the person with dementia. proceedings can be viewed in the ‘methods used in reviews’ sec-
• Observer or carer ratings of everyday functioning (activities tion within the editorial information about the Dementia and
of daily living) of the person with dementia. Cognitive Improvement Group (CDCIG).
• Carer ratings of the participant’s behaviour. Additional searches in each of the sources listed above, to cover
• Clinician or carer ratings of neuropsychiatric symptoms or the timeframe from the last searches performed for the Specialized
behaviour problems of the person with dementia. Register to December 2011, were run to ensure that the search for
• Clinician or carer ratings of the social engagement of the the review was as up to date as possible. The search strategies used
person with dementia. can be seen in Appendix 1.
A total of 804 references were retrieved from the December 2011
’Carer’ in this context included care staff as well as family care-
search. After de-duplication and a first assessment, authors were
givers.
left with 41 references to further assess for either inclusion, exclu-
sion or discarding.
Outcomes for the family caregiver
The outcomes for the family caregiver that were considered in-
cluded any of the following. Data collection and analysis
• Self-reported well-being, depression and anxiety. Searches were conducted as detailed above to identify all relevant
• Self-reported burden, strain and coping. published studies. The date and time of each search, together with
• Satisfaction with the intervention. 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.
Search methods for identification of studies
We searched ALOIS (
www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cog- Quality assessment
nitive Improvement Group Specialized Register, on 6 December RCTs were identified and the two review authors (BW and EA)
2011. The search terms used were: cognitive stimulation, reality worked independently to determine which studies met the criteria
orientation, memory therapy, memory groups, memory support, for inclusion. Trials that did not meet the criteria were excluded,
memory stimulation, global stimulation, cognitive psychostimu- and reasons for exclusion were noted in the table ’Characteristics
lation. of excluded studies’. Review authors’ selections of trials were com-
ALOIS is maintained by the Trials Search Co-ordinator of the pared and the final list of included studies was reached by consen-
Cochrane Dementia and Cognitive Improvement Group and con- sus.
tains studies in the areas of dementia prevention, dementia treat- The selected RCTs were described in tabular form, permitting an
ment and cognitive enhancement in healthy populations. The evaluation of their methodological quality. Studies were assessed
studies are identified from: against a checklist of quality requirements using the Cochrane
1. monthly searches of a number of major healthcare approach (see risk of bias tables).
databases: MEDLINE, EMBASE, CINAHL, PsycINFO and • Grade A, ’Low risk’: adequate concealment (randomisation;
LILACS; concealed allocation).

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 • Grade B, ’Unclear risk’: “randomised”, but methods was the weighted mean difference when the pooled trials used the
uncertain. same rating scale or test and the standardised mean difference (the
• Grade C, ’High risk’: inadequate concealment of allocation absolute mean difference divided by the standard deviation) when
or no randomisation, or both. they used different rating scales or tests. The duration of the trials
may vary considerably. If the review authors considered the range
Only trials with a grade A or B ranking were included in the re-
too great to combine all trials into one meta-analysis, they divided
view. Again, the review authors worked independently to ascertain
it into smaller time periods and conducted a separate meta-analy-
which studies met the quality criteria, and consensus was reached
sis for each period. Some trials may have contributed data to more
through discussion. Attempts were made to obtain additional in-
than one time period if multiple assessments were made.
formation from the study authors when further data were needed.
The meta-analyses presented overall estimates of the treatment
difference from a fixed-effect model and a test for heterogeneity
Data extraction was performed using a standard Chi2 statistic. Where there was
evidence of heterogeneity of the treatment effect between trials
Data from the RCTs selected for inclusion were extracted, recorded
then a random-effects model was utilised (which results in broader
and entered into RevMan. The summary statistics required for
confidence intervals than for those of a fixed-effect model).
each trial and each outcome for continuous data were the mean
The review authors discussed and reached consensus on the in-
change from baseline, the standard error of the mean change, and
terpretation of the statistical analyses, seeking specialist statistical
the number of patients for each treatment group at each assess-
advice from CDCIG as required. The review authors discussed
ment point. Where changes from baseline were not reported, the
and reached consensus on the presentation of the findings in the
review authors extracted the mean, standard deviation and the
background to the review.
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-
RESULTS
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
Description of studies
sought the numbers in each treatment group and the numbers See: Characteristics of included studies; Characteristics of
experiencing the outcome of interest. The baseline assessment was excluded studies; Characteristics of studies awaiting classification;
defined as the latest available assessment prior to randomisation, Characteristics of ongoing studies.
but no longer than two months prior. From the initial set of references identified by the updated sys-
For each outcome measure, data were sought on every patient tematic searches (since our last review, Spector 2000a), 53 po-
randomised. To allow an intention-to-treat analysis, the data were tentially relevant studies were identified. Of these, seven studies
sought irrespective of compliance and whether or not the patient met the inclusion criteria (Baldelli 2002; Bottino 2005; Chapman
was subsequently deemed ineligible or otherwise excluded from 2004; Onder 2005; Requena 2006; Spector 2001; Spector 2003)
treatment or follow-up. If intention-to-treat data were not avail- and were included in this review. Our previous review (Spector
able in the publications, ’on-treatment’ data or the data of those 2000a) included eight studies in the meta-analysis, six of which
who completed the trial were sought and were indicated as such. were included in this replacement review (Baines 1987; Baldelli
In studies where a cross-over design was used, only data from the 1993a; Breuil 1994; Ferrario 1991; Wallis 1983; Woods 1979).
first treatment phase after randomisation were eligible for inclu- For the two studies excluded at this stage, the data needed for the
sion. current analyses were not available (Gerber 1991; Hanley 1981).
As the outcomes measured in clinical trials of dementia and cog- Full details of included studies and reasons for exclusion of ex-
nitive impairment often arise from ordinal rating scales, where the cluded studies are presented in the tables ’Characteristics of in-
rating scales had a reasonably large number of categories (more cluded studies’ and ’Characteristics of excluded studies’. The pre-
than 10) the data were treated as continuous outcomes arising publication search in December 2011 identified 41 further stud-
from a normal distribution. 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
Data analysis 2011; Fernandez-Calvo 2010; Niu 2010).
The meta-analyses included the combination of data from trials Overall, 718 participants, 407 in the treatment groups and 311
that may not use the same rating scale to assess an outcome. There- in the control groups, were included in the analyses of the 15 in-
fore, the measure of the treatment difference for any outcome used cluded studies. The included studies varied in many aspects: (1)

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 6

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
participant characteristics; (2) number and duration of cognitive Participants were resident in care homes, nursing homes or hospi-
stimulation sessions; (3) activities which defined cognitive stim- tals, apart from six studies (Bottino 2005; Breuil 1994; Buschert
ulation; (4) the activity of the control group; and (5) outcome 2011; Chapman 2004; Onder 2005; Requena 2006) where all the
measures. These factors will be considered in turn. 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,
1) Participant characteristics with the former being in the majority.

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 2) Length, number and duration of sessions
used DSM-IV criteria, but did not break the participants down The length of the intervention varied from four weeks (the min-
by dementia subtype; Baldelli 2002 included similar numbers of imum for inclusion in the review) to 24 months, with the stated
participants with “Degenerative senile dementia of the Alzheimer’s length of sessions varying from 30 minutes to 90 minutes. In
type (SDAT)” (N = 46) and “vascular multi-infarct dementia” general, the sessions of longer duration were associated with the
(N = 41), although all had experienced at least one cerebrovascu- lowest frequency (once a week). The median session length across
lar accident resulting in motor deficits; Bottino 2005, Buschert the studies was 45 minutes, and the median frequency was three
2011, Chapman 2004, Onder 2005 and Requena 2006 all speci- times a week, ranging from once to five times a week. The total
fied a diagnosis of probable Alzheimer’s disease (AD) according to possible exposure to the intervention varied dramatically, from 10
NINCDS-ADRDA criteria linked with either ICD-10 or DSM- to 12 hours (Baines 1987; Breuil 1994; Chapman 2004; Coen
IIIR criteria. In these studies, participants were on a stable dose 2011; Spector 2001; Spector 2003) to 375 hours in the two-year
of an acetylcholinesterase inhibitor (ACHEI) (rivastigmine in the (Requena 2006) study. Across the 15 studies, the median exposure
Bottino 2005 study; donepezil in the remaining studies apart from time was 30 hours. Requena 2006 presented data from both the
Buschert 2011 where a variety of medications including meman- 12 month and 24 months time point in their study. As there was
tine were being taken). Amongst the earlier studies, Breuil 1994 less attrition at the 12 month time point, and this was more com-
specified DSM-III criteria for dementia and Baldelli 1993a stated parable (although still longer) in duration to the other studies, the
that their participants were diagnosed with “Alzheimer’s (SDAT) 12 month data were used in combination with other studies in the
”. The four studies from 1991 and earlier specified more general meta-analyses, with the 24 month data reported separately.
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 3) Activities during cognitive stimulation
on the Mini-Mental State Examination (MMSE), and the 11th The level of detail provided in the published papers regarding the
(Ferrario 1991) provided the MMSE score range for participants. activities undertaken varied greatly. All studies used small group
Coen 2011, Spector 2001 and Spector 2003 were the only studies sessions, typically with groups of five to seven participants, with
with a mean MMSE score in the moderate range (10 to 20), per- the exception of Onder 2005 where family caregivers were taught
haps reflecting the upper limit of 24 for participants to be included to carry out cognitive stimulation with the person with dementia
in these studies. The mean scores (16.9, 13.1 and 14.4 respec- on an individual basis. These individual sessions, led by family
tively) were several points lower than those in the eleven studies caregivers, included current information, topics of general interest,
reporting mean scores (mean average 19.7), and outside the range historical events and famous people, attention, memory and visuo-
of 18 to 25 specified by Ferrario 1991. However, those studies spatial exercises and the use of clocks, calendars and notes.
where the mean score was in the mild range (> 20) may well have Early studies described the use of an RO board and discus-
included participants in the moderate or even the severe range, for sion of current orientating information through newspapers, pho-
example the lowest score in the Breuil 1994 study was reported to tographs, calendars and clocks etc., with materials selected to stim-
be 9. In general, however, it can be said that the studies included ulate all five senses (for example Baines 1987; Wallis 1983; Woods
in this review had targeted participants in the mild to moderate 1979). Breuil 1994 introduced a number of more specific cogni-
range of cognitive impairment. tive activities including drawing, associating words, object nam-
The average age of participants was over 70 years in all studies ing and categorising. Spector 2006 provided a detailed session by
(except Wallis 1983 where it was 69.8 years); in 6 studies it was session treatment manual for the approach used in their studies.
over 80 years. The average mean age across the 15 studies was Activities in their sessions were designed with four themes: (1) the
78.8 years, with the range of ages that were reported from 38 to senses, (2) remembering the past, (3) people and objects, and (4)
97 years. Over half the studies reported inclusion of participant(s) everyday practical issues. Activities included naming objects and
aged 90 years and above. people, association of words, remembering the past, discussion of

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
hobbies, activities and current affairs, using money, knowing the form. Four studies used a self-report quality of life measure with
way around and orientation topics. This treatment manual was participants with dementia (Buschert 2011; Chapman 2004; Coen
also used by Coen 2011. Chapman 2004 reported topics includ- 2011; Spector 2003), but again the Chapman 2004 data was not
ing current events, discussion of hobbies and activities, education in a useable form. Five studies used a self-report depression mea-
regarding Alzheimer’s disease, life story work, and links with daily sure (four making use of a version of the Geriatric Depression
life with groups of six to seven participants. Bottino 2005 described Scale: Yesavage 1983), and four studies used a depression or anx-
temporal and spatial orientation, discussion of interesting themes, iety scale completed from carer reports as well as from interviews
reminiscence activities, naming people, planning of daily activities with the participants (such as the Cornell Scale for Depression in
and use of calendars and clocks and other external memory aids. Dementia: Alexopoulos 1988). A variety of scales have been used
Requena 2006 described, for groups of five people with dementia, to evaluate behaviour, with activities of daily living (ADL) scales
visual images being shown on a TV screen from a computer and used in four studies, general behaviour ratings in seven studies
that reflected seven themes: orientation, bodily awareness, family and problem behaviour scales used in three studies. Family care-
and society, caring for oneself, reminiscing, household activities, giver outcome measures were used in three studies (Bottino 2005;
animals, people and objects. These were accompanied by ques- Onder 2005; Spector 2001).
tions for discussion. A full list of the outcome measures used in the included studies
None of the included trials adopted 24 hour RO in addition to can be found in the table Characteristics of included studies’.
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
Risk of bias in included studies
out at home between sessions and Onder 2005 encouraged family
caregivers to informally engage in reality-based communication Details for each study are provided in the ’Characteristics of in-
with the person with dementia two or three times a day. cluded studies’ table.

Allocation
4) Control group(s) activities
For a study to be included in this review, the review authors had
In the earlier studies, alternative group activities were offered that to be satisfied that random allocation to treatment conditions had
were of a social (Woods 1979) or diversional (Wallis 1983) na- been used. To ascertain this, in several cases it was necessary to seek
ture. Baines 1987 offered an alternative treatment, reminiscence further information from the study authors (for example Baldelli
groups, but for the purposes of this review it was the no-treatment 1993a; Baldelli 2002; Ferrario 1991; Requena 2006). Remote or
group that was included in the analyses. ’Treatment as usual’ or computerised randomisation was only used in four of the most
no treatment was the control condition in a number of studies recent studies (Bottino 2005; Chapman 2004; Buschert 2011).
(Baldelli 1993a; Breuil 1994; Coen 2011; Ferrario 1991; Spector Earlier studies described drawing names from a hat or a sealed
2001; Spector 2003). In those studies where participants were also container, where it was possible to obtain details of the randomi-
taking ACHEIs, the control group were typically monitored in sation procedure.
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 Blinding
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.
Performance bias
With psychological interventions, unlike drug trials, it is impos-
sible to totally blind participants and staff to treatment. Partici-
5) Outcome measures pants will often be aware that they are being treated preferentially
As a condition of inclusion, cognitive tests were used in all the and the staff involved may have different expectations of treat-
studies. Eleven studies used the MMSE (Folstein 1975) and eight ment groups. There may also be ’contamination’ between groups
of the more recent studies also used the Alzheimer’s Disease As- in terms of group sessions not being held in separate rooms and
sessment Scale - Cognitive (ADAS-Cog) (Rosen 1984). Unfortu- staff bringing ideas from one group to another, so that control
nately, only the 10 month follow-up data on these and other mea- participants receive elements of cognitive stimulation. The latter
sures could be utilised from Chapman 2004 as it has not proved effect would be reduced with clear therapeutic protocols, the ex-
possible to obtain their data at earlier time points in an extractable istence of which was not clear in most study reports.

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In relation to contamination, Wallis 1983 and Baines 1987 both attrition in the group of participants with dementia. In this study
stated that the staff were unaware of the allocation of participants patients who attended less than 20% of the group sessions were
to groups, as they were removed from the ward setting for treat- eliminated from the study. Requena 2006 reported 32% attrition
ment, and several other studies described the groups being run in but this was over a two year period. The two largest studies had
a separate or specific room (for example Ferrario 1991; Spector rates of 19% (Onder 2005) and 17% (Spector 2003) over periods
2001; Spector 2003; Woods 1979). of six months and two months respectively.

Other potential sources of bias

Detection bias The absence of detailed treatment protocols raised queries regard-
Most studies took steps to ensure that at least part of the assessment ing the extent to which the cognitive stimulation was delivered
of outcomes was carried out by assessors blind to treatment allo- as intended (having noted that there may have been differences
cation. Only three studies (Baldelli 1993a; Baldelli 2002; Ferrario in emphases between studies in any case). Several studies noted
1991) did not report blinding of assessors. Of course, even inde- that staff received training or supervision, or both, in running the
pendent assessors may be given clues from participants during the groups and, from an early study, Woods 1979 stated in a personal
assessments, but this was not reported as an issue in the studies communication that “A sample of sessions were tape-recorded and
reviewed here. Using independent assessors works well for evalu- rated to ensure compliance with the therapeutic protocol”. More
ating changes in cognition or self-reported mood, well-being and recently, Chapman 2004 described weekly meetings to ensure their
quality of life. Ratings of day-to-day behaviour and function are treatment programme was implemented as designed. Subgroups
typically carried out by care staff, who may be more difficult to were led by a licensed speech-language pathologist and three mas-
keep blind to group allocation, unless the group sessions were car- ter’s level speech-language pathology students; all underwent two
ried out in a separate location to which all participants were taken. 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
Incomplete outcome data multi-disciplinary team and given a manual and specific schedules
for each session. No records were made, however, of how often
Only two studies described following an intention-to-treat analy-
caregivers did deliver the sessions, or how closely the manual was
sis plan (Chapman 2004; Spector 2003). In contrast, Breuil 1994
followed.
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). Effects of interventions
All studies reported data on attrition. Given the nature of the con- For meta-analyses we used RevMan 5.1.
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 Cognition
attrition rate was reported by Wallis 1983 where there was 39% (See Figure 1)

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 Figure 1. Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome:
Cognition.

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
For the overall evaluation of the effects of cognitive stimulation
on cognitive function, all 14 RCTs which included useable data and control groups was 2.27 points (95% CI 0.99 to 3.55), a
immediately post-treatment were included, including a total of statistically significant difference (Z = 3.48, P < 0.0005). In to-
658 people with dementia of whom 377 received cognitive stim- tal, 10 studies involving 600 participants used the MMSE (Figure
ulation and 281 received no treatment or a placebo treatment. As 3). The overall mean difference was 1.74 points (95% CI 1.13
most studies included more than one measure of cognitive func- to 2.36). Again, this was a statistically significant difference (Z =
tion, this analysis was conducted on the most extensive assessment 5.57, P < 0.00001). These analyses were strongly influenced by
included. For seven studies this was the ADAS-Cog, and for two two of the more recent studies, Spector 2003 and Onder 2005,
each it was the MMSE and CAPE Information/Orientation scales. which were relatively large and had smaller confidence intervals
The overall effect size, the standardised mean difference (SMD) around their reported mean differences. Five of the older studies
was 0.41 (95% CI 0.25 to 0.57). This was a statistically significant involving 81 participants used other measures of information or
finding (Z = 5.04, P < 0.00001). For the seven studies, including orientation (Figure 4); here the SMD was no smaller (SMD 0.45,
434 participants, using the ADAS-Cog as an outcome measure 95% CI -0.01 to 0.90) and was just statistically significant despite
(Figure 2), the mean difference between the cognitive stimulation 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.

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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.

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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 tinued exposure (ADAS-Cog SMD 0.66: MD 11.94 points, 95%
1993a study (SMD 0.99 on MMSE), both of which offered above CI -0.97 to 24.85; MMSE SMD 0.56: MD 5.99 points, 95% CI
average durations of exposure to cognitive stimulation. However, -1.58 to 13.56). However, these effects require replication as the
Breuil 1994, which offered only 10 hours exposure, also had an confidence intervals were broad and crossed zero.
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
Communication and social interaction
indicated that effect sizes appeared to be maintained through con-
(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)

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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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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 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.

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Five studies, involving 201 participants, used a self-report measure
of mood (the Geriatric Depression Scale or the MADRS). Cog- scale and the fourth the Rating of Anxiety in dementia. The SMD
nitive stimulation was not associated with a clear improvement in was close to zero in this domain (SMD 0.05, 95% CI -0.21 to
mood across these studies. The SMD was 0.22 (95% CI -0.09 to 0.31).
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 Behaviour
Depression in Dementia, a third using a subscale of the MOSES (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.

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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; tion (SMD -0.14, 95% CI -0.44 to 0.17) (Z = 0.86, P = 0.39).
a second focused on behaviours seen as a problem, such as irritabil- General behaviour rating scales showed a similar picture, with no
ity, being demanding and difficult. The third included ’general’ difference emerging. Eight studies, including 416 participants, re-
behaviour rating scales, which may include some of the previous ported data on relevant scales (SMD 0.13, 95% CI -0.07 to 0.32)
two aspects, together with some higher level daily living skills. (Z = 1.30, P = 0.20).
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- Caregiver outcomes
cluding 166 participants, used scales evaluating behaviour prob-
lems. Again there was no difference related to cognitive stimula- (See Figure 12)

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 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 The analyses for assessments carried out after the intervention had
cognitive stimulation, so the effects on caregivers were especially been completed were reported in two groups: Baines 1987 and
pertinent for that study. The effect sizes for anxiety, depression and Wallis 1983 had a one month follow-up, and Baldelli 1993a a
caregiver burden were all close to zero (SMDs 0.11, 0.04, -0.03 three month follow-up on certain measures. These three studies
respectively), with confidence intervals crossing zero indicating represent a short term follow-up; whereas Chapman 2004 reported
no differences between the caregivers in the cognitive stimulation useable data only from a 10 month follow-up, a much longer
condition and those in the control conditions. period in the context of the progression of dementia.
Only one study (Baines 1987) reported outcomes for care staff, so For cognitive measures (Figure 13), the three older studies with
no meta-analysis was possible. The results of this study indicated short term follow-up reported data for 52 participants. The signif-
a significant increase in staff knowledge about residents partici- icant advantage for cognitive stimulation on cognitive measures
pating in the cognitive stimulation intervention compared with seen immediately post-treatment remained at this point (SMD
knowledge of residents in the control condition. 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
Follow-up 0.12) at the 10 month follow-up.

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 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.

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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.

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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.

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
DISCUSSION 2000). In relation to the number needed to treat (NNT) for one
more participant in the treatment group than in the control group
In total, 15 RCTs with a total of 718 participants (407 receiving to benefit by a certain amount, Spector 2003 and Onder 2005
cognitive stimulation, 311 in control groups) met the inclusion provide some evidence. For an improvement of 4 or more points
criteria for the meta-analyses. The most striking finding reflects on the ADAS-Cog, Spector 2003 calculated an NNT of 6, and
the effects of cognitive stimulation on performance in tests of cog- Onder 2005 14, figures broadly comparable to those seen in trials
nitive function. The results of the meta-analyses reported here in- of the ACHEIs.
dicate that cognitive stimulation programmes for dementia have
a significant positive effect on cognition, which is evident in the However, as has been pointed out repeatedly over the years (Woods
post-2000 studies included in this review as well as in the older 2006), changes in cognition are not sufficient to justify an exten-
studies which were included in our previous review of Reality Ori- sive programme of intervention, unless they are accompanied by
entation. This is perhaps the most consistent finding in the liter- other changes, in behaviour and well-being. Here there are two
ature on psychological interventions with people with dementia. positive findings. Firstly, results from four RCTs (with 223 par-
The studies included here came from a variety of countries and ticipants) indicated that positive changes in communication and
contexts, from France, the UK, Italy, Spain and Brazil; from hospi- social interaction were evident in staff ratings outside the context
tal, care home, nursing home, day centre and outpatient settings; of the cognitive stimulation group sessions. Secondly, results from
and administered in groups by staff or volunteers, or individually four RCTs (219 participants) identified a benefit on quality of life
by family caregivers. and well-being associated with cognitive stimulation.

The extent to which these changes in cognitive function are clini- In contrast, there was no indication that cognitive stimulation was
cally important has not been generally addressed. An average ben- associated with changes in mood, whether self-rated or rated by
efit of 1.74 points on the MMSE or 2.27 points on the ADAS- staff, or in behaviour including activities of daily living and self-
Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 21
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
care and problem behaviour. It is notable that in general there is scribed ACHEI medication. For the four of these RCTs providing
much less evidence available regarding these domains compared post-treatment data, the additional effect of cognitive stimulation
with that available for changes in cognition. No benefits to family over and above the medication was 3.18 points on the ADAS-
caregivers were identified in terms of mood or caregiver burden. Cog, compared with the overall finding (from seven RCTs) of 2.27
However, it is important to note that in the study where the re- points. This supports the proposition that cognitive stimulation
sponsibility for delivering the cognitive stimulation fell on famiy is effective irrespective of whether or not ACHEIs are prescribed,
caregivers (Onder 2005), this additional task did not appear to and any effects are in addition to those associated with the med-
add to their stress and strain. One study showed an improvement ication. One study (Requena 2006) reported comparative results
in care home staff knowledge of residents following participation from a control group who received neither cognitive stimulation
in cognitive stimulation. nor an ACHEI, but this was not a randomly allocated condition
so that the additive effects of these two treatment approaches were
There is little evidence available on the cost-effectiveness of cog- not established compared with no treatment. Such a study would
nitive stimulation (CST). Knapp 2006 reported cost-effective- perhaps not now be seen as ethical in a context where ACHEIs are
ness acceptability curves for cognition and quality of life from the seen as standard treatment for Alzheimer-type dementia.
Spector 2003 trial and conclude that, for both outcomes, ’under
reasonable assumptions, there is a high probability that CST is In general, it appears that outcome measures rated by staff are less
more cost-effective than treatment as usual’. likely to indicate positive change than those that are completed by
the person with dementia directly with an assessor blinded to the
These findings all relate to the assessment point immediately af-
treatment received. In a care home or hospital context, it is well
ter the treatment period has been completed. Only four relatively
known that achieving consistent staff ratings in research studies
small studies reported data on whether any changes were main-
such as these is a major challenge. It can often be impossible to
tained after a period of follow-up without further intervention.
have the same staff member rate the person at each time point due
Here, again, cognition stands out with three RCTs showing a pos-
to staff turn-over and sickness. There can be a ’drift’ in ratings over
itive effect evident at a follow-up of one to three months after
time, even with the same rater. The observation period and op-
the intervention; this was not evident in the one RCT reporting a
portunities for observation may vary over time. Maintaining staff
10 month follow-up. Other follow-up data were limited in their
blind to treatment allocation is more challenging than for an as-
extent and scope but there were no indications of benefits in the
sessor who only visits the facility to carry out the assessments. The
areas of behaviour and well-being that were evaluated.
one area of staff-rated behaviour showing change in this review re-
A key area of difference between studies relates to the duration lates to communication and social interaction, an area that has not
and frequency of the cognitive stimulation offered, leading to a been highlighted in previous reviews of this type of intervention.
wide variation in the ’dosage’ of cognitive stimulation received, as Given the social emphasis of cognitive stimulation groups, this is
indicated by the total number of hours of stimulation offered. As an area of behaviour that is most closely linked to the content of
pointed out previously, there does not appear to be a clear relation- the intervention. Indeed, Spector 2010 have demonstrated that
ship between dosage and the effect size on cognitive function in the in their study language function was an area of specific cognitive
various studies; the Spearman’s correlation was 0.25 (N = 14, P = improvement.
0.392). It is difficult to ascertain whether the frequency of sessions
per week makes a difference as the study with the largest effect Inevitably where the control condition is ’no treatment’, the ques-
sizes (Requena 2006) has five 45-minute sessions per week and tion is raised as to whether any benefits associated with the treat-
has the longest duration. As the duration increases, the anticipated ment arise from non-specific effects such as meeting as a group,
decline associated with dementia should tend to reduce the effects socialising, increased attention and so on. A few early studies did
of cognitive stimulation, and so a simple linear relationship is un- include an ’attention’ control group (Woods 1979) or diversional
likely to hold. One study (Requena 2006) continued cognitive occupational therapy (Wallis 1983) and one study offered physi-
stimulation for two years. The decision was made to include one cal rehabilitation sessions to both groups (Baldelli 2002). In the
year data from this study in the primary meta-analyses reported Requena 2006 study where stimulation materials were presented
here, to reduce the impact of attrition. However, the effects on on a TV screen to the group, control participants watched TV
cognition and self-reported mood appeared to be sustained over a elsewhere. Although we cannot provide a definitive conclusion on
further one year period, although the effects were not statistically this matter, our results did not indicate any effects of these dif-
significant in our analyses. There is a need for further research ferent control conditions on outcome. In a mediation analysis,
on maintenance cognitive stimulation, looking at whether lower- Woods 2006 demonstrated that in the Spector 2003 RCT the im-
intensity input maintains gains from an initial period of cognitive provements in quality of life were mediated by improvements in
stimulation (Aguirre 2010). cognition, suggesting that it is the cognitive focus of the cognitive
stimulation therapy programmes (rather than merely the social
In five of the included studies all of the participants were pre- contact and attention) which lead to improved well-being. Fur-

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 22

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ther work is required to explore the relationship between changes ble to draw on any evidence on the strengths and benefits of these
in cognition and the changes in well-being and quality of life and different treatment modalities.
communication that are emerging from the current review.
The range of severity of dementia experienced by patients in-
The quality of the included studies is variable, and generally low, cluded in the studies reviewed here ranged from mild to moder-
with lack of clarity regarding randomisation procedures being evi- ate. There was no indication that the two studies with the lowest
dent in around half the studies (including some of the more recent mean MMSE scores of participants (Spector 2001; Spector 2003)
studies). CONSORT type diagrams depicting the flow of partic- had any different effects than those with more mildly impaired
ipants through the trial are provided by four of the recent studies participants. Most studies included a mixture of participants with
(Bottino 2005; Buschert 2011; Onder 2005; Spector 2003) and, mild and moderate dementia. Onder 2005 indicated that there
along with remote, independent randomisation, will be a mini- was no differential benefit to either group, with no significant in-
mum expectation in future trials. The number of participants in- teraction between severity of dementia and treatment on change
cluded has increased markedly from an average of 23 per study in either MMSE or ADAS-Cog scores. More work may be needed
prior to 2000 to 64 in the nine more recent studies. Larger sample to define if there are people with dementia, or subgroups, who
sizes will necessitate multi-centre trials, for example Spector 2003 are more or less likely to benefit from a cognitive stimulation in-
recruited from 23 centres. This will have implications for analy- tervention. No analyses have been attempted here seeking to es-
ses, with cluster effects within a centre, even though participants tablish whether different subtypes of the dementias show specific
are individually randomised. Spector 2003 accordingly included responses to cognitive stimulation. One study (Baldelli 2002) in-
centre as a covariate in their analyses. Studies do not yet appear cluded only participants who had had a cerebrovascular accident
to have taken account of clustering effects arising from a group (CVA), although less than half the participants had a diagnosis of
intervention. This occurs where changes in group members are vascular dementia. Most recent studies have included those who
not entirely independent. Group leaders often report that some are receiving AChEI medication, with a probable Alzheimer’s diag-
groups seem to work much better than others for example. Inten- nosis, whereas Spector 2003 included all types of dementia. Given
tion-to-treat analyses were only described by two (recent) studies, that the average age of participants across the review was almost
although in most cases details of attrition were reported. The need 80 years (over 85 in the Spector 2003 study), it is highly likely that
for assessors to be blind to treatment allocation is widely recog- neurodegenerative and vascular changes are co-occurring in the
nised and attempted in most studies. More attention may need to majority of participants, and so the distinction may be of limited
be given in future studies to demonstrating the extent to which pragmatic utility.
the cognitive stimulation is delivered as planned. Well-developed
treatment manuals will help with assuring the replicability of the The findings of this review are broadly in line with other more
intervention. In general, there is a clear improvement in overall wide-ranging reviews of non-pharmacological interventions in de-
quality of the included studies over time, for example in the more mentia. Livingston 2005 gives a relatively strong recommendation
consistent information given regarding the diagnosis of partici- for cognitive stimulation in relation to its effects on neuropsychi-
pants and the criteria used, as well as the use of consistent outcome atric symptoms, including mood, but notes some inconsistencies
measures and larger sample size. in the evidence on these outcomes. Sitzer 2006 included 17 studies
in their meta-analysis of ’cognitive training’ in Alzheimer’s disease,
The studies included in the review utilised therapists with a variety four of which met our definition of ’cognitive stimulation’ and
of backgrounds, experience and training. They included volun- three of which are included in this review. Sitzer 2006 concludes
teers, family caregivers, speech and language therapists, occupa- that there is a medium effect size (0.47) across all types of ’train-
tional therapists, nurses, care workers and research staff. There are ing’ over the whole range of outcome measures, making ’cogni-
no indications from this review of the amount or type of training tive training’ a promising intervention. However, it is notewor-
required to deliver cognitive stimulation, although there is broad thy that general stimulation techniques were prominent in four
agreement that whilst training is needed the therapist does not of the five trials reporting the most beneficial results, with the
need a professional qualification. Given the concerns regarding RO review describing these as ’restorative strategies’. Olazaran 2010
being delivered in a mechanical, dehumanising fashion (Dietch reviewed 179 RCTs across 26 categories of non-pharmacological
1989), training and supervision in person-centred care would be interventions. They concluded that there was ’Grade B’ evidence
seen as a prerequisite for delivery of cognitive stimulation. In this (consistent evidence from lower quality RCTs) for cognitive stim-
review, there were no reported side effects or adverse effects of any ulation in relation to cognition, behaviour and psychological well-
of the cognitive stimulation interventions. Attrition was due to being. They did not identify any ’Grade A’ evidence (consistent ev-
expected reasons in studies of this nature: illness, death, transfer to idence from high quality RCTs) for any interventions with people
another facility and occasional refusal to complete follow-up as- with dementia, although some caregiver interventions did reach
sessments. With only one study utilising an individual approach, this level. The 2011 World Alzheimer’s Report (Prince 2011) con-
in contrast to offering group cognitive stimulation, it is not possi- cludes, from a wide-ranging systematic review, “We found strong

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 23

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
evidence (multiple RCTs) that acetylcholinesterase inhibitors (for must be acknowledged that these could represent a biased sample
cognitive function, functional impairment), and cognitive stimu- of the studies undertaken world-wide on this topic. In many fields
lation (for cognitive function) are effective interventions in mild of endeavour, trials that are not successful (that is do not produce
dementia” and makes the following recommendation in relation the expected positive findings) are less likely to be published. This
to interventions for early-stage dementia: “Acetylcholinesterase in- may be especially the case with smaller trials. The welcome trend
hibitors and cognitive stimulation may enhance cognitive func- to pre-registration of trials, and the publication of trial protocols,
tion in people with mild Alzheimer’s disease, and these interven- makes this less likely to occur in the future in relation to larger,
tions should therefore be routinely offered.” well-funded trials. The meta-analyses here have been influenced
strongly by the larger trials included (such as Spector 2003 and
Finally, consideration should be given to the possibility of publica- Onder 2005), and a funnel plot of the cognition outcome appears
tion bias in this domain. By reviewing only the studies on cognitive reasonably symmetrical (Figure 18) suggesting that possible pub-
stimulation that have been published in peer-reviewed journals, it 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.

consistently demonstrated, with small changes reported in multi-

ple trials on commonly used brief measures of cognitive function;
AUTHORS’ CONCLUSIONS adverse effects have not been reported. There is now evidence from
Implications for practice a small number of studies that cognitive stimulation may also be
associated with improvements in quality of life and communica-
The evidence base for the effectiveness of cognitive stimulation
tion. These benefits are over and above any medication effects.
therapy for dementia in relation to cognitive function has been
Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 24
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
This review is consistent with the NICE-SCIE 2006 Guideline there benefits in terms of increased participation in activities of
recommendation that all people with mild to moderate demen- importance to the person, increased social inclusion or of individ-
tia should have the opportunity to participate in cognitive stim- ual goals being attained?
ulation groups, irrespective of whether or not they are receiving
Only one cost-effectiveness study has been identified to date and
acetylcholinesterase inhibiting medication (ACHEIs). This rec-
this gap should be addressed, particularly in relation to clinically
ommendation was recently reinforced by the World Alzheimer’s
meaningful benefits.
Report (Prince 2011).
Although more research is needed, results from one study suggest Finally, the implementation of cognitive stimulation in real-life
that continuing involvement in cognitive stimulation may be ben- settings needs to be addressed. The key issue here is whether the
eficial. results obtained by those who attend brief training in the methods
or make use of one of the treatment manuals that have been de-
Implications for research veloped, or both, are comparable to those obtained in the context
of research studies and RCTs.
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 ACKNOWLEDGEMENTS
pathways; and their linkage, if any, with outcomes such as mood,
Maintenance Cognitive Stimulation Programme (IS-
quality of life, day-to-day function and behaviour.
RCTN26286067) is part of the Support at Home - Interventions
There is a clear need for more randomised controlled trials of cog- to Enhance Life in Dementia (SHIELD) project (Application No
nitive stimulation exploring the long term benefits of this inter- RP-PG-0606-1083) which is funded by the NIHR Programme
vention. The effects of severity of dementia and different modali- Grants for Applied research funding scheme. The grant holders
ties (for example group versus with caregiver) need to be system- are Professors Orrell (UCL), Woods (Bangor), Challis (Manch-
atically evaluated. These RCTs may be of particular value if used ester), Moniz-Cook (Hull), Russell (Swansea), Knapp (LSE) and
in conjunction with more qualitative studies in order to under- Dr Charlesworth (UCL). The views and opinions expressed in this
stand the relationships between the different outcome measures. review are those of the authors and do not necessarily reflect those
The clinical meaningfulness of any benefits needs to be examined, of the Department of Health/NIHR. The authors wish to thank
particularly in relation to the impact of any cognitive changes. Are Joanne Knowles for acting as consumer reviewer for this review.

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Olazaran 2004 {published data only} Schreiber M, Lutz K, Schweizer A, Kalveram KT, Jancke L.
Olazaran J, Muniz R, Reisberg B, Pena-Casanova J, del Development and evaluation of an interactive computer-
Ser T, Cruz-Jentoft AJ, et al.Benefits of cognitive-motor based training as a rehabilitation tool for dementia.
intervention in MCI and mild to moderate Alzheimer Psychologie Beitrage 1998;40(1):85–102.
disease. Neurology 2004;63:2348–53. Schreiber 1999 {published data only}
Orrell 2000b {published data only} Schreiber M, Schweizer A, Lutz K, Kalveram KT, Jancke
Orrell M. Evidence based psychological therapy package for L. Potential of an interactive computer-based training
dementia. National Research Register 2000b. in the rehabilitation of dementia: an initial study.
Neuropsychological Rehabilitation 1999;9(2):155–67.
Orrell 2005 {published data only}
Orrell M, Spector A, Thorgrimsen L, Woods B. A pilot Scott 2003 {published data only}
study examining the effectiveness of maintenance Cognitive Scott J, Clare L. Do people with dementia benefit from
Stimulation Therapy (MCST) for people with dementia. psychological interventions offered on a group basis?.
International Journal of Geriatric Psychiatry 2005;20: Clinical Psychology and Psychotherapy 2003;10(3):186–96.
446–51. Smith 2009 {published data only}
Quayhagen 1995 {published data only} Smith GE, Housen P, Yaffe K, Ruff R, Kennison RF,
Quayhagen MP, Quayhagen M, Corbeil RR, Roth PA, Mahncke HW, Zelinski EM. A cognitive training program
Rodgers JA. A dyadic remediation program for care based on principles of brain plasticity: Results from the
recipients with dementia. Nursing Research 1995;44(3): improvement in memory with plasticity- based adaptive
153–9. cognitive training (IMPACT) study. Journal of the American
Geriatrics Society 2009;57(4):594–603.
Quayhagen 2000 {published data only}
Quayhagen MP, Quayhagen M, Corbeil RR, Hendrix Spector 2008 {published data only}
RC, Jackson JE, Snyder L, et al.Coping with dementia: Spector A, Woods B, Orrell M. Cognitive stimulation
Evaluation of four non pharmacologic interventions. for the treatment of Alzheimer’s disease. Expert Review of
International Psychogeriatrics 2000;12(2):249–65. Neurotherapeutics 2008;8(5):751–7.

Raggi 2007 {published data only} Tadaka 2004 {published data only}
Raggi A, Iannaccone S, Marcone A, Ginex V, Ortelli P, Tadaka E, Kanagawa K. A randomized controlled trial of a
Nonis A, et al.The effects of a comprehensive rehabilitation group care program for community-dwelling elderly people
program of Alzheimer’s Disease in a hospital setting. with dementia. Japan Journal of Nursing Science 2004;1:
Behavioural Neurology 2007;18(1):1–6. 19–25.
Tarraga 2005a {published data only}
Reeve 1985 {published data only}
Tarraga L. Randomised pilot study to evaluate the efficacy
Reeve W, Ivison D. Use of environmental manipulation and
of an interactive multimedia system for the cognitive
classroom and modified informal reality orientation with
stimulation of Alzheimer’s disease patients. 1st International
institutionalized, confused elderly patients. Age and Ageing
Consensus Conference Non pharmacological Therapies for
1985;14(2):119–21.
Alzheimer’s, Madrid, May 12-13. 2005:35–6.
Riegler 1980 {published data only}
Tarraga 2005b {published data only}
Riegler J. Comparison of a reality orientation program for
Tarraga L, Badenas S, Modinos G, Espinosa A, Diego S,
geriatric patients with and without music. Journal of Music
Balcells J, et al.Randomized Pilot Study To Evaluate the
Therapy 1980;17(1):26–33.
Efficacy of an Interactive Multimedia Internet-Based Tool
Ruiz Sanchez de Leon 2007 {published data only} for the Cognitive Stimulation of Patients with Alzheimer’s
Ruiz Sanchez De Leon JM, Llanero Luque M. Computer- Disease. 57th Annual Meeting of the American Academy of
based cognitive training and donepezil: Combined therapy Neurology, Miami Beach, April 2005. 2005:P01.138.
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Tarraga 2006 {published data only} Zanetti 2004 {published data only}
Tarraga L, Boada M, Modinos G, Espinosa A, Diego S, Zanetti O, Calabria M, Cotelli M. Effectiveness of the
Morera A, et al.A randomised pilot study to assess the association of donepezil and Reality Orientation Therapy.
efficacy of an interactive, multimedia tool of cognitive Giornale di Gerontologia 2004;52(5):480–411.
stimulation in Alzheimer’s disease. Journal of Neurology, Zepelin 1981 {published data only}
Neurosurgery & Psychiatry 2006;77:1116–21. Zepelin H, Wolfe CS, Kleinplatz F. Evaluation of a year
Tarraga 2007 {published data only} long reality orientation program. Journal of Gerontology
Tarraga L, Boada M, Modinos G, Espinosa A, Diego S, 1981;36(1):70–7.
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computer and Alzheimer’s disease. Neuroscientist 2007;13 Zientz J, Rackley A, Chapman SB, Hopper T, Mahendra
(2):97. N, Cleary S. Evidence-based practice recommendations:
Caregiver-administered active cognitive stimulation for
Thickpenny-Davis 2007 {published data only}
individuals with Alzheimer’s disease.. Journal of Medical
Thickpenny-Davis KL, Barker-Collo SL. Evaluation of a
Speech-Language Pathology 2007;15(3):27–34.
structured group format memory rehabilitation program for
adults following brain injury. The Journal of Head Trauma References to studies awaiting assessment
Rehabilitation 2007;22:303–13.

Tsai 2008 {published data only} Buettner 2011 {published data only}
Tsai AY, Yang M, Lan C, Chen C. Evaluation of effect Buettner LL, Fitzsimmons S, Atav S, Sink K. Cognitive
of cognitive intervention programs for the community- stimulation for apathy in probable early-stage Alzheimer’s.
dwelling elderly with subjective memory complaints. Journal of Aging Research 2011. [DOI: 10.4061/2011/
International Journal of Geriatric Psychiatry 2008;23(11): 480890]
1172–4. Fernandez-Calvo 2010 {published data only}
Fernandez-Calvo B, Contador I, Serna A, de Lucena VM,
Wenisch 2005 {published data only}
Ramos F. The effect of an individual or group intervention
Wenish E, Stoker A, Bourrellis C, Pasquet C, Gauthier
format in cognitive stimulation of patients with Alzheimer’s
E, Corcos E, et al.A global intervention program for
disease. [El efecto del formato de intervencion individual
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o grupal en la estimulacion cognitiva de pacientes con
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enfermedad de Alzheimer]. Revista de Psicopatología y
Wenisch 2007 {published data only} Psicología Clínica 2010;15:115–23.
Wenisch E, Cantegreil-Kallen I, De Rotrou J, Garrigue Niu 2010 {published data only}
P, Moulin F, Batouche F, et al.Cognitive stimulation Niu YX, Tan JP, Guan JQ, Zhang ZQ, Wang LN. Cognitive
intervention for elders with mild cognitive impairment stimulation therapy in the treatment of neuropsychiatric
compared with normal aged subjects: preliminary results. symptoms in Alzheimer’s disease: a randomized controlled
Aging Clinical & Experimental Research 2007;19(4):316–22. trial. Clinical Rehabilitation 2010;24:1002–1011. [DOI:
10.1177/0269215510376004]
Wettstein 2004 {published data only}
Wettstein A, Schmid R, Konig M. Who participates in References to ongoing studies
psychosocial interventions for caregivers of patients with
dementia?. Dementia and Geriatric Cognitive Disorders Aguirre 2010 {published data only}
2004;18(1):80–6. Aguirre E, Spector A, Hoe J, Russell IT, Knapp M,
Woods RT, Orrell M. Maintenance Cognitive Stimulation
Williams 1987 {published data only}
Williams R, Reeve W, Ivison D, Kavanagh D. Use of Therapy (CST) for dementia: A single-blind, multi-centre,
randomized controlled trial of Maintenance CST vs. CST
environmental manipulation and modified informal reality
orientation with institutionalized, confused elderly subjects: for dementia. Trials 2010;11:46.
a replication. Age and Ageing 1987;16(5):315–8. Vidovich 2011 {published data only}
Vidovich MR, Shaw J, Flicker L, Almeida OP. Cognitive
Woods 2006 {published data only} activity for the treatment of older adults with mild
Woods B, Thorgrimsen L, Spector A, Royan L, Orrell M. Alzheimer’s disease (AD)--PACE AD: study protocol for a
Improved quality of life and cognitive stimulation therapy randomised controlled trial.. Trials 2011;12:47.
in dementia. Aging & Mental Health 2006;10(3):219–26.
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in Alzheimer disease: Useful or not? A controlled study. Cornell Scale for Depression in Dementia. Biological
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APA 1997 NICE-SCIE 2006
American Psychiatric Association. Practice guideline for the NICE-SCIE. Dementia: Supporting people with dementia
treatment of patients with Alzheimer’s disease and other and their carers in health and social care: Clinical Guideline
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154 Suppl(5):1–39.
Olazaran 2010
Burton 1982 Olazaran J, Reisberg B, Clare L, Cruz I, Pena-Casanova J, del
Burton M. Reality orientation for the elderly: a critique. Ser T, et al.Non-pharmacological therapies in Alzheimer’s
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Clare 2003 Geriatric Cognitive Disorders 2010;30:161–78.
Clare L, Woods RT, Moniz Cook ED, Orrell M, Spector Powell-Proctor 1982
A. Cognitive rehabilitation and cognitive training for early- Powell-Proctor L, Miller E. Reality orientation: a critical
stage Alzheimer’s disease and vascular dementia. Cochrane appraisal. British Journal of Psychiatry 1982;140:457–63.
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385–401. Rosen 1984
Dietch 1989 Rosen WG, Mohs RC, Davis KL. A new rating scale for
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orientation. Journal of American Geriatrics Society 1989;37: 141:1356–64.
974–6. Sitzer 2006
Folstein 1975 Sitzer D, Twamley E, Jeste D. Cognitive training in
Folstein MF, Folstein SE, McHugh PR. ’Mini Mental State’: Alzheimer’s disease: a meta-analysis of the literature. Acta
a practical method for grading the cognitive state of patients Psychiatrica Scandinavica 2006;114(2):75–90.
for the clinician. Journal of Psychiatric Research 1975;12:
189–98. Small 2002
Small GW. What we need to know about age related
Holden 1995
memory loss. BMJ 2002;324:1502–5.
Holden UP, Woods RT. Positive approaches to dementia care.
3rd Edition. Edinburgh: Churchill Livingstone, 1995. Spector 2000b
Hughes 1982 Spector A, Orrell M, Davies S, Woods RT. Reality
Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. orientation for dementia. Cochrane Database of Systematic
A new clinical scale for the staging of dementia. The British Reviews 2000, Issue Issue 3. Art. No.: CD001119. [DOI:
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Knapp 2006 Spector 2006
Knapp M, Thorgrimsen L, Patel A, Spector A, Hallam A, Spector A, Thorgrimsen L, Woods B, Orrell M. Making
Woods B, Orrell M. Cognitive stimulation therapy for a difference: an evidence-based group programme to offer
people with dementia: cost-effectiveness analysis. British cognitive stimulation therapy (CST) to people with dementia.
Journal of Psychiatry 2006;188:574–80. London: Hawker Publications, 2006.
Livingston 2005 Spector 2010
Livingston G, Johnston K, Katona C, Paton J, Lyketsos Spector A, Orrell M, Woods B. Cognitive Stimulation
CG. Systematic review of psychological approaches to the Therapy (CST): effects on different areas of cognitive
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American Journal of Psychiatry 2005;162(11):1996–2021. Geriatric Psychiatry 2010;25:1253–8.
McGilton 2003 Taulbee 1966
McGilton KS, Rivera TM, Dawson P. Can we help persons Taulbee LR, Folsom JC. Reality orientation for geriatric
with dementia find their way in a new environment?. Aging patients. Hospital & Community Psychiatry 1966;17:133–5.
& Mental Health 2003;7(5):363–71.
Woods 1977
Mohs 2000
Woods RT, Britton PG. Psychological approaches to the
Mohs R. Neuropsychological assessment of patients with
treatment of the elderly. Age & Ageing 1977;6:104–12.
Alzheimer’s disease. In: Bloom FE, Kupfer DJ editor(s).
Psychopharmacology: 4th generation of progress. American Woods 2002
College of Neuropsychopharmacology, 2000:http:// Woods B. Editorial: Reality Orientation: a welcome return?
www.acnp.org/publications/psycho4generation.aspx. . Age & Ageing 2002;31:155–6.

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Yesavage 1983
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References to other published versions of this review

Spector 2000a
Spector A, Davies S, Woods B, Orrell M. Reality orientation
for dementia: a systematic review of the evidence for its
effectiveness. Gerontologist 2000;40(2):206–212.
∗
Indicates the major publication for the study

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 31

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES

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 Unclear risk No details of the randomisation method
bias) 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 Low risk RO groups held in separate areas;
bias)
All outcomes

Blinding of outcome assessment (detection Low risk Cognitive assessments made by an inde-
bias) pendent psychologist; other ratings made
All outcomes by staff not involved in the therapy groups

Incomplete outcome data (attrition bias) Low risk No attrition at follow-up assessment
All outcomes

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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 Unclear risk Stated by e-mail that their trials were randomised (with no detail
bias) 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 Unclear risk No evidence of blinding in the paper
bias)
All outcomes

Blinding of outcome assessment (detection Unclear risk No details of who assessors were
bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk Zero attrition at 3 month post-treatment assessment; no attrition
All outcomes 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

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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 Unclear risk Stated by e-mail that their trials were randomised (with no detail
bias) 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 Unclear risk No evidence of blinding in the paper
bias)
All outcomes

Blinding of outcome assessment (detection Unclear risk No details of assessors given

bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk No attrition reported

All outcomes

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

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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 Low risk Randomised blocks design, randomly allocated to either group
bias) 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 Low risk Assessment made by assessors blinded to group allocation
bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk No attrition reported

All outcomes

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 Unclear risk No details of randomisation reported

bias)

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Breuil 1994 (Continued)

Allocation concealment (selection bias) Unclear risk No details of randomisation reported

Blinding of outcome assessment (detection Low risk Cognitive assessments made by an assessor blind to group allo-
bias) cation; ADL assessment open
All outcomes

Incomplete outcome data (attrition bias) Low risk Five patients excluded as did not attend all training and evalua-
All outcomes 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 Low risk Blocked randomisation procedure; participants pooled in pairs
bias) 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 Unclear risk Assessors blind to group allocation
bias)
All outcomes

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Buschert 2011 (Continued)

Incomplete outcome data (attrition bias) Low risk No attrition

All outcomes

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 Low risk Independent randomisation, using an SAS procedure
bias)

Allocation concealment (selection bias) Low risk Remote telephone randomisation

Blinding (performance bias and detection Unclear risk Carer ratings not blind to allocation
bias)
All outcomes

Blinding of outcome assessment (detection Low risk All raters underwent extensive training; assessors blinded to
bias) group allocation
All outcomes

Incomplete outcome data (attrition bias) Low risk Intention to treat analysis used. 24% attrition rate at end of
All outcomes study

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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 Unclear risk Stated that participants were randomly assigned. Author con-
bias) 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 Unclear risk Staff running groups also involved in other activities, involving
bias) control participants
All outcomes

Blinding of outcome assessment (detection Unclear risk Tests administered by staff blind to group membership. Not
bias) clear if staff ratings were made by staff who wre blinded
All outcomes

Incomplete outcome data (attrition bias) Unclear risk No attrition

All outcomes

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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 Unclear risk Stated by e-mail that the trial was randomised (with no detail of
bias) 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 Unclear risk No information given in relation to where groups were held,
bias) but RO materials were in evidence on the ward - may have been
All outcomes accessed by control participants?

Blinding of outcome assessment (detection Unclear risk MOSES completed by nursing staff - not clear if raters were
bias) blind
All outcomes

Incomplete outcome data (attrition bias) Low risk 2 dropouts (/21). 1 in each group (pneumonia and stroke). (In-
All outcomes formation provided by the author)

Other bias Low risk RO administered by volunteers trained by physicians and psy-
chologist

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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 Low risk Computerised block randomisation process
bias)

Allocation concealment (selection bias) Low risk Computerised block randomisation process

Blinding of outcome assessment (detection Low risk Assessment made by blind assessors
bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk Attrition data reported: 9 from RO group, 10 from control group
All outcomes 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

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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 Unclear risk Randomisation by registration order: ’subjects were randomly
bias) 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 Low risk Spanish paper stated that groups were led by an independent
bias) member of the research team
All outcomes

Blinding of outcome assessment (detection Low risk Spanish paper states ’Evaluator was blind to treatment allocation’
bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk Attrition reported: 6/20 in CS + donepezil group; 10/30 in
All outcomes 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

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 41

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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 Low risk Randomly allocated to either group by drawing names from a
bias) 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 Unclear risk Not clear whether staff and carer ratings were made blind to
bias) treatment allocation
All outcomes

Blinding of outcome assessment (detection Low risk Cognitive assessments made by a blind assessor
bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk Attrition reported: 4 in CS group, 4 in control group i.e. 23%
All outcomes

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

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 42

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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 Low risk Randomly allocated to either group by drawing names from a
bias) 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 Low risk Members of staff involved in groups did not carry out ratings,
bias) but ratings by other staff may not have been blind
All outcomes

Blinding of outcome assessment (detection Low risk Cognitive assessments and quality of life interview conducted
bias) by a blind assessor
All outcomes

Incomplete outcome data (attrition bias) Low risk 34/201 did not complete study (18 CS / 16 controls); 17%
All outcomes 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

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 43

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Wallis 1983 (Continued)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Drawing from a hat and consecutive allocation
bias)

Allocation concealment (selection bias) Low risk Drawing from a hat and consecutive allocation

Blinding (performance bias and detection Low risk Setting of treatment separate to assessment settings
bias)
All outcomes

Blinding of outcome assessment (detection Low risk Assessors unaware of group allocation
bias)
All outcomes

Incomplete outcome data (attrition bias) Unclear risk Eliminated those attending less than 20% of sessions; 12/31
All outcomes 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 Low risk Stated that drawing from a hat was used
bias)

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Woods 1979 (Continued)

Allocation concealment (selection bias) Unclear risk Stated that drawing from a hat was used

Blinding (performance bias and detection Low risk ’Social therapy’ was perceived by staff as an active therapy
bias)
All outcomes

Blinding of outcome assessment (detection Low risk Groups held in separate areas and assessors bind to group allo-
bias) cation
All outcomes

Incomplete outcome data (attrition bias) Low risk 4/18 dropped out: i.e. 22.2% attrition
All outcomes

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

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(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.

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(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.

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(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]

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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

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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

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DATA AND ANALYSES

Comparison 1. Cognitive stimulation versus no cognitive stimulation: post-treatment

No. of No. of
Outcome or subgroup title studies 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 1 56 Std. Mean Difference (IV, Fixed, 95% CI) 0.63 [0.09, 1.17]
(includes MMSE & CERAD)
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 10 600 Mean Difference (IV, Fixed, 95% CI) 1.74 [1.13, 2.36]
CS
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 7 434 Mean Difference (IV, Fixed, 95% CI) 2.27 [0.99, 3.55]
CS
3.2 24 months of CS 1 29 Mean Difference (IV, Fixed, 95% CI) 11.94 [-0.97, 24.85]
4 Other cognitive measure: 5 81 Std. Mean Difference (IV, Fixed, 95% CI) 0.45 [-0.01, 0.90]
Information/Orientation
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 4 223 Std. Mean Difference (IV, Fixed, 95% CI) 0.44 [0.17, 0.71]
interaction
5.1 Holden Communication 3 204 Std. Mean Difference (IV, Fixed, 95% CI) 0.47 [0.18, 0.75]
Scale
5.2 MOSES - Withdrawn 1 19 Std. Mean Difference (IV, Fixed, 95% CI) 0.10 [-0.86, 1.07]
behaviour
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 3 160 Std. Mean Difference (IV, Fixed, 95% CI) 0.34 [-0.01, 0.70]
Scale (GDS-30) One to twelve
months of CS
7.2 Geriatric Depression 1 26 Std. Mean Difference (IV, Fixed, 95% CI) -0.39 [-1.16, 0.39]
Scale (14 item) One to twelve
months of CS
7.3 Montgomery Asberg 1 15 Std. Mean Difference (IV, Fixed, 95% CI) 0.31 [-0.72, 1.33]
Depression Rating Scale
(MADRS) One to twelve
months of CS
8 Mood: Staff-reported 4 239 Std. Mean Difference (IV, Fixed, 95% CI) 0.05 [-0.21, 0.31]
Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 51
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 8.1 Cornell Scale for 2 194 Std. Mean Difference (IV, Fixed, 95% CI) 0.01 [-0.28, 0.30]
Depression in Dementia
8.2 MOSES - Depressed / 1 19 Std. Mean Difference (IV, Fixed, 95% CI) -0.01 [-0.98, 0.96]
anxious mood
8.3 Rating of Anxiety in 1 26 Std. Mean Difference (IV, Fixed, 95% CI) 0.38 [-0.40, 1.16]
Dementia (RAID)
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 1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.40 [-0.86, 1.66]
Rating Scale
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 1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.94 [-0.41, 2.29]
Questionnaire (GHQ-12)

Comparison 2. Cognitive stimulation versus no cognitive stimulation: follow-up

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Cognition 4 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 One to three months 3 52 Std. Mean Difference (IV, Fixed, 95% CI) 0.57 [0.01, 1.14]
follow-up Information/
Orientation
1.2 Ten months follow-up 1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.18 [-0.35, 0.72]
MMSE
1.3 Ten months follow-up 1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.12 [-0.41, 0.66]
ADAS-Cog
2 Well-being & Quality of Life 2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 One month follow-up Life 1 10 Std. Mean Difference (IV, Fixed, 95% CI) -0.03 [-1.27, 1.21]
Satisfaction Index
2.2 Ten months follow-up 1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.34 [-0.19, 0.88]
QoL-AD
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 1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.43 [-0.11, 0.97]
Texas Functional Living Scale
4 Behaviour, problem 2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 52
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 4.1 One month follow-up 1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.39 [-0.87, 1.65]
Problem Behaviour Rating
Scale
4.2 Ten month follow-up NPI 1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.29 [-0.24, 0.83]
severity
4.3 Ten-month follow up NPI 1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.41 [-0.13, 0.95]
(Caregiver Distress)
5 Communication and social 2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
interaction
5.1 One month follow-up 1 10 Std. Mean Difference (IV, Fixed, 95% CI) 0.20 [-1.05, 1.44]
Holden Communication Scale
5.2 Ten month follow-up 1 54 Std. Mean Difference (IV, Fixed, 95% CI) 0.15 [-0.39, 0.68]
’Relevance of discourse’

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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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 . . . )

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 (. . .Continued)
Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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

Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 54

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 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

Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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%

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 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

Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive Stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive Stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive Stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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%

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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

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 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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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

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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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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

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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

Std. Std.
Mean Mean
Study or subgroup Cognitive stimulation Control Difference Weight 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

APPENDICES
Appendix 1. Search: December 2011

Source Search strategy Hits retrieved

1. ALOIS (www.medicine.ox.ac.uk/alois) cognitive stimulation OR reality orienta- 139

(all dates) tion OR memory therapy OR memory
groups OR memory support OR mem-
ory stimulation OR global stimulation OR
cognitive psychostimulation

2. MEDLINE In-process and other non- 1. exp Dementia/ 40

indexed citations and MEDLINE 1950- 2. Delirium/
present (Ovid SP) 3. Wernicke Encephalopathy/
4. Delirium, Dementia, Amnestic, Cogni-

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(Continued)

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)).
sh.
44. 42 not 43
45. 33 and 44

3. EMBASE 1. exp dementia/ 239

1980-2011 Dec 05 (Ovid SP) 2. Lewy body/
3. delirium/
Cognitive stimulation to improve cognitive functioning in people with dementia (Review) 71
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(Continued)

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

4. PsycINFO 1. exp Dementia/ 29

1806-November week 5 2011 (Ovid SP) 2. exp Delirium/
3. exp Huntingtons Disease/
4. exp Kluver Bucy Syndrome/
5. exp Wernickes Syndrome/
6. exp Cognitive Impairment/
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

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(Continued)

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+”) 34

S2 (MH “Delirium”) or (MH “Delir-
ium, Dementia, Amnestic, Cognitive Dis-
orders”)
S3 (MH “Wernicke’s Encephalopathy”)
S4 TX dement*
S5 TX alzheimer*
S6 TX lewy* N2 bod*
S7 TX deliri*
S8 TX chronic N2 cerebrovascular
S9 TX “organic brain disease” or “organic
brain syndrome”

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(Continued)

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* 135

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
“psychomotor performance” OR “global
stimulation” OR “cognitive performance”)
AND Topic=(random* OR trial* OR RCT
OR “cross-over” OR cross-over) AND Year

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(Continued)

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- 16

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]

8. CENTRAL (The Cochrane Library) (Is- #1 dement* 35

sue 3 of 4, Oct 2011) #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)
#25 (#24), from 2010 to 2011

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(Continued)

9. Clinicaltrials.gov ( #1 Intervention: Cognitive stimulation 51

www.clinicaltrials.gov) 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

10. ICTRP Search Portal (http:/ Advanced search: (dementia OR alzheimer 86

/apps.who.int/trialsearch) [includes: Aus- OR alzheimers OR alzheimers) AND (cog-
tralian New Zealand Clinical Trials Reg- nitive stimulation OR reality orientation
istry; ClinicalTrilas.gov; ISRCTN; Chinese OR memory therapy OR memory training
Clinical Trial Registry; Clinical Trials Reg- OR cognitive training) AND (2010-2011)
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]

TOTAL before de-duplication 804

TOTAL after de-dupe and first-assess 41

HISTORY
Protocol first published: Issue 4, 2005
Review first published: Issue 2, 2012

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CONTRIBUTIONS OF AUTHORS
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.

DECLARATIONS OF INTEREST
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.

SOURCES OF SUPPORT
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.

NOTES
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).

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.