Part of the core CMHT work of the South Norfolk CMHT is to assess and diagnose people with having a dementia. Alongside pharmacological interventions, the NICE guidance NG97 recommends people with a mild to moderate dementia are offered group CST, as part of promoting cognition, independence and wellbeing. Our 4 Support Workers and Assistant Practitioners now commit to running CST groups as part of our core CMHT work. This allows us to consider offering all people newly diagnosed with dementia by the CMHT, the option to attend a 14-session course of group CST. Up to 4 groups are run at each time with 2 leaders running each session. 15 people are invited to each group allowing us to offer CST to at least 200 people each year.
Aims and objectives
We were keen to offer people recently diagnosed with dementia the opportunity to maximise their cognition, independence and wellbeing – in addition to reducing social isolation. A group allows people to meet others in a similar situation and offers some normalizing of experiences. We felt this could minimise feelings of isolation. Prior to this intervention, people diagnosed with dementia were offered recommended pharmacological interventions and support as usual as available within the local area.
Group CST offers a manualised treatment approach for people with dementia and it has an evidence base (Spector et al., 2003). It incorporates well-used interventions such as Reality Orientation, Reminiscence work and multi-sensory approaches to implicit learning. By delivering this within the context of good person-centred care and supervised practice with appropriately trained staff, research shows that CST offers a psychological evidence-based treatment for people with dementia.
CST focuses on implicit learning and offers a supportive, familiar & consistent learning environment. This can serve to boost confidence and self-esteem. Throughout the group, use of discussion, thinking and interacting is actively encouraged to increase confidence in communicating. Reminiscence & multi-sensory stimulation to encourage recall.
Our groups include signposting in the latter sessions. People are encouraged to consider further groups and suggestions are based on the knowledge staff have built about a person over the course of the group. In some cases, coming to CST can motivate people to consider attending longer term groups that they wouldn’t necessarily have considered otherwise. As a team we recognise that people often feel valued being part of a group and in realising they are not alone in having dementia. Some participants have created social connections that have continued beyond the group. In this sense, the CST groups can serve as a ‘stepping stone’, enabling people to access longer-term support that might strengthen future coping strategies.
We were keen to offer additional support post diagnosis and to enable a smooth transfer back to the CMHT if people were thought to be facing difficulties managing their mood as part of accepting and adjusting to a diagnosis of dementia. Offering group CST as part of core CMHT work enables this as staff running the groups are able to monitor wellbeing. Where concerns are raised people can quickly be re-assessed.
Reasons for implementing your project
CST was developed by a Clinical Psychologist and her colleagues over a number of years. In 2003 they published the results of a randomised controlled trial. CST was shown to lead to significant improvements in cognition (MMSE score +0.9) and quality of life (QOL-AD score +1.3). The demonstrated benefits of CST appear to compare favourably with acetylcholinesterase inhibitors. This led to the UK Government NICE guidance (2006, 2018) on the management of dementia to recommend the use of group Cognitive Stimulation for people with mild to moderate dementia, irrespective of drug treatments received.
Working as part of a CMHT we are particularly interested in management of mood. We were interested in how CST has been shown to improve ratings of quality of life in people with dementia. We felt this may offer a proactive means of supporting people with dementia post diagnosis and work to reduce the likelihood of crises occurring.
How did you implement the project
The first CST group was run within the Norfolk and Suffolk Foundation NHS Trust (NSFT) back in 2008. Feedback was positive and following this initial trial, we arranged a CST training session for staff. The Team Leader has supported staff in creating the time to run CST groups as part of their core team work. It was felt that the reduced hours staff would subsequently have for general clinical work would be offset by a reduction in referrals for additional support/input post-diagnosis, given the CST intervention.
In the South Central Norfolk Older People’s Community Mental Health Team, approximately 4 CST groups are now run on a rolling programme. The groups meet weekly for 14 weeks and are led by Angie Smith and Donna Adams, Support Workers at Bickley Day Services and Shirley Wright, Assistant Practitioner and Katie Howe, Support Worker at the Julian Hospital. Early on in running the groups, staff realised that a major hurdle to attending the CST group was transport provision. Staff have worked hard with hospital transport to ensure that all people interested and able to attend CST are offered volunteer transport which can be offered at no cost to patients.
Other members of the CMHT help out in offering cover where needed. Group leaders meet regularly Psychology to discuss any issues or themes within the groups and share experiences and learning. The current provision of groups offered means that everyone diagnosed with dementia in the south central team, who is interested and considered suitable for CST group treatment, is offered a place.
The results of a mini service evaluation carried out within the team confirmed that CST is a useful intervention to consider for people with dementia. In particular, ratings of quality of life appeared to show improvement over the course of the group. Most participants reported attending CST groups to be helpful. One gentleman spoke of how he had felt quite depressed at receiving his diagnosis of dementia. He believed attending CST helped him regain self-esteem and had served to improve his mood. Many people reported that attending the CST group helps them to improve in confidence.
Key learning points
- Cognitive Stimulation Therapy (CST) groups can offer a useful addition to the work of a core Community Mental Health Team (CMHT). The ‘in-house’ provision allows for further support and monitoring of mood after receiving a diagnosis of dementia.
- Offering CST as part of core CMHT work allows people to be quickly referred back to access additional support from the CMHT where concerns are highlighted. This appears to work to reduce the likelihood of crises occurring.
- CST allows for the opportunity for people to make social connections that can continue beyond the group. Attending CST groups can serve as a ‘stepping stone’, enabling people to access longer-term support that might strengthen future coping strategies. Group leaders note that by getting to know people over the course of the group they are able to better tailor suggestions for further support available in the community. This information may also be helpful in guiding further person-centred support that may be needed in the future.
- Accessing the groups appeared a potential barrier for some – particularly in rural areas like south Norfolk. The group leaders felt it was essential to be able to offer hospital transport for people to attend CST that was provided at no cost to patients.