Cognitive stimulation therapy: A new approach to treating Alzheimer’s

by Carol Aloysius

The rapidly graying population in Sri Lanka and worldwide has led to a surge in dementia and Alzheimer's disease. According to recent surveys around 200,000 or more persons have been identified as having memory loss.

While many of them are well into their seventies and over, the disturbing news is that younger persons, some of them in their fifties are now showing symptoms of memory loss.

Alzheimer's cannot be cured. But early detection can delay symptoms. Patients with advanced dementia or Alzheimer's need full time care. New approaches to stimulate the minds of patients are now being tried out. One of them is Cognitive therapy.

The Sunday Observer spoke to experts in the field, Dr Rebecca Johnson, Dr Timothy Kember (both clinical psychologists from UK) and Intern clinical psychologist Leilani de Silva of University of Kelaniya what the therapy involves.

Excerpts…

Q. What are the main reasons leading to Alzheimer's?

A. There is no one single cause of Alzheimer's disease. It’s a combination of factors and conditions that increase a person’s risk of developing the disease.

The biggest risk factor is age; the older a person gets, the more likely they will develop Alzheimer's disease (Az). While women are more likely to develop Alzheimer's than men, other existing health conditions increase the risks of getting the disease.

Q. Such as?

A. Conditions that affect the heart, arteries or blood circulation all significantly affect a person's chances of developing dementia, particularly vascular dementia. These conditions include diabetes, mid-life high blood pressure and high blood cholesterol levels, mid-life obesity, heart problems (such as a heart attack or irregular heart rhythms) and stroke. Stroke is a major risk factor for dementia - it is thought that a history of stroke doubles the risk of dementia in the older population.

Smoking and excessive alcohol use increase the risk of developing Alzheimer’s disease.

Depression may be linked with increased likelihood of developing dementia.

Other medical conditions that can increase a person's chances of developing dementia include Parkinson's disease, multiple sclerosis, chronic kidney disease and HIV. Down's syndrome and some other learning disabilities also increase a person's risk of Dementia.

Q. What are the early symptoms?

A. The National Health Services (NHS) in UK identifies the following symptoms of mild Alzheimer’s disease: forgetfulness, mood swings, speech problems. The UK Alzheimer’s Society has advised family members to seek help if they notice the following symptoms in any member of the family:

* Struggling to remember recent events, although they can easily recall things that happened in the past.

* Finding it hard to follow conversations or programmes on TV.

* Forgetting the names of friends or everyday objects

* Cannot recall things you have heard, seen or read

* Repeating oneself of losing the thread of the conversation in the middle of a sentence..

* Having problems thinking and reasoning.

* Feeling anxious, depressed or angry about one’s forgetfulness

* Finding that other people start to comment on your forgetfulness

* Feeling confused even when in a familiar environment.

Q. Can these symptoms be prevented? Delayed?

A. There is no certain way to prevent dementia. However the risk factors can be reduced by following the above instructions.

Q. Is Alzheimer's curable?

A. There is currently no cure for Alzheimer's disease. However, drug treatments are available that can temporarily alleviate some symptoms or slow down their progression in some people.

Q. What are the probable causes? Fast ageing populations? Stress? Loneliness? Breakdown of relationships? Psychological problems? Neurological disorders? Brain injuries?

A. There is no one single cause of Alzheimer’s disease. A number of factors that increase a person’s risk of developing Alzheimer’s disease have been identified. In summary the biggest risk factor is age; the older a person gets, the more likely they will develop Alzheimer’s disease. Women are more likely to develop Az than men.

“Conditions that affect the heart, arteries or blood circulation all significantly affect a person's chances of developing dementia, particularly vascular dementia. These conditions include diabetes, mid-life high blood pressure and high blood cholesterol levels, mid-life obesity, heart problems (such as a heart attack or irregular heart rhythms) and stroke. Stroke is a major risk factor for dementia - it is thought that a history of stroke doubles the risk of dementia in the older population (Alzheimer's’ Society)

Smoking and excessive alcohol use increase the risk of developing Alzheimer’s disease. Depression may be linked with increased likelihood of developing dementia. Other medical conditions that can increase a person's chances of developing dementia include Parkinson's disease, multiple sclerosis, chronic kidney disease and HIV.

Down's syndrome and some other learning disabilities also increase a person's risk of dementia (Alzheimer’s society). At the same time, there are also factors that REDUCE a persons risk of developing Alzheimer’s disease, such as a healthy diet, exercise and keeping the mind active (reading, puzzles etc).

Q. What are the early symptoms?

A. NHS identifies the following symptoms of mild Alzheimer’s disease: forgetfulness, mood swings, speech problems.

The UK Alzheimer’s Society advises those presenting these symptoms to seek help if they notice the following symptoms.

* Struggle to remember recent events, although you can easily recall things that happened in the distant past.

* Find it hard to follow conversations or programs on TV

* Forget the names of friends or everyday objects

* Cannot recall things you have heard, seen or read

* Notice that you repeat yourself or lose the thread of what you are saying.

* Have problems thinking and reasoning

* Feel anxious, depressed or angry about your forgetfulness

* Find that other people start to comment on your forgetfulness

* Feel confused even when in a familiar environment.

Q. Can they be prevented? Delayed?

A. There is no certain way to prevent dementia. However the risk factors can be reduced as mentioned earlier.

Q. Is Alzheimers curable?

A. There is currently no cure for Alzheimer's disease. However, drug treatments are available that can temporarily alleviate some symptoms or slow down their progression in some people.

Q. Dr Johnson and Dr Kember, you have both specialised in Cognitive Stimulation Therapy ( CST) in the UK. Tell us what it involves as it is relatively a very new concept in Sri Lanka.? Is it a psychosocial intervention? Elaborate.

A. CST is a group intervention, based on a number of key principles. It involves themed group activities.

Q. Are drugs included, reduced, eliminated in this therapy?

A. No. CST is not used instead of dementia medication. A person attending CST would continue taking dementia medication as prescribed by a psychiatrist.

Q. How long does the therapy usually last? How many sessions do patients need to follow?

A. CST consists of 14 weekly sessions.

Q. Is it designed for all people with Alzheimer’s disease or for specific groups e.g. those with mild to moderate Alzheimer's?

A. It is for mild to moderate Alzheimer's.

Q. What about those with more severe Alzheimer’s?

A. People with more severe Alzheimer’s disease, would not be able to engage in a group therapy such as CST. The evidence base for medications is also less clear.

When people are in this stage of the disease, our care approach is usually focused on improving the person’s quality of life as much as possible.

Q. How different is this from the traditional approach?

A. CST incorporates elements from a number of different psychosocial interventions which have arisen over the past 50 years or so e.g. Reality Orientation, Validation Therapy, Reminiscence Therapy, Multi-sensory Stimulation.

It combines the best elements from each, as well as adding an emphasis on ‘new learning’.

It has a number of key principles which are applied explicitly or implicitly throughout the 14 week program e.g. always asking ‘opinion’ questions and never asking for facts (e.g. ‘what do you like about this persons face?’, NOT 'who is this?’). This helps to avoid failure and is more cognitively stimulating and encourages a more interesting discussion.

Q. What kind of activities do they follow during the sessions?

A. CST has a different themed activity each week, e.g. ‘Faces’ (where you may discuss famous faces, what you prefer about them, who you would rather be etc), ‘Food’ (where you’d try different foods, think about what would go into different meals, discuss favourites etc), ‘Orientation’ (where you’d look at old maps, old and new photos of their area etc), ‘Childhood’ (where you discuss elements of their childhood, what is different for children born nowadays etc).

Q. What are the techniques used for these activities?

A. In each session we would try to use different props e.g. real food, to help engagement and trigger stimulation.

Q. What are the benefits in 1) the short run? 2) Long run? Do you have any feedback?

A.CST has been shown to have a positive impact on a persons language skills after the 14-weeks program.

It also has a positive impact on quality of life.

Q. How?

A. Anecdotally, people are able to form relationships with other group members, it gives carers a short break, and people have fun - so it’s a positive experience for the person with dementia and very importantly, for their carer for whom it is a 24 hour job.

Q. Have there been any further new developments in CST?

A. Dementia is progressive so people’s cognitive functioning etc. will always decline, however CST may help to slow this progression down.

A longer program called ‘Maintenance CST’ has recently been developed which is another 20 sessions of CST that can help people remain engaged in the group and may help to prolong the benefits.

Q. Who should one contact for more details on this subject?

A. If anyone wants more information they can refer to Stimulation Therapy (MCST) for people with dementia. In the International Journal of Geriatric Psychiatry 20.5 (2005): 446-451.

Q. Ms de Silva, as a spokesperson for the Lanka Alzheimers Foundation (LAF) of which Ms Lorraine Yu is the President, tell us what inputs your organisation has made in this field.

A. The Lanka Alzheimer's Foundation (LAF) is an approved charity (Gazette Notification No. 1225), incorporated in 2001 and registered with the Ministry of Social Services.

LAF is the first non-statutory organisation dedicated to advocating and addressing the needs of those diagnosed with cognitive impairment and dementia.

We provide education and support for individuals with dementia as well as their families.

We also conduct a memory clinic and training.

Q. Do you also provide Cognitive Stimulation Therapy?

A. Not at present. But we intend doing so later this year.

Q. As you mentioned, the number of patients with dementia are increasing in Sri Lanka. If anyone needs help from your organisation who should they contact?

A. LAF is located in Ketawalamulla Lane, Colombo 10, with a new service centre created through donations to provide specific services including day care for persons with mild to moderate dementia, in addition to diagnostic and memory testing service, counselling, and consultation by medical professionals, information and a lending library.

There are also activities and awareness programs available for the very young, young and adult members of the community. Our telephone number is 2583488.

Functional brain imaging predicts patients' recovery process

A functional brain imaging technique known as positron emission tomography (PET) is a promising tool for determining which severely brain damaged individuals in vegetative states have the potential to recover consciousness, according to new research.

It is the first time that researchers have tested the diagnostic accuracy of functional brain imaging techniques in clinical practice. “Our findings suggest that PET imaging can reveal cognitive processes that aren't visible through traditional bedside tests, and could substantially complement standard behavioural assessments to identify unresponsive or “vegetative” patients who have the potential for long-term recovery”, says study leader Prof Steven Laureys from the University of Liége in Belgium.

In severely brain-damaged individuals, judging the level of consciousness has proved challenging. Traditionally, bedside clinical examinations have been used to decide whether patients are in a minimally conscious state (MCS), in which there is some evidence of awareness and response to stimuli, or are in a vegetative state (VS) also known as unresponsive wakefulness syndrome, where there is neither, and the chance of recovery is much lower. But up to 40 percent of patients are misdiagnosed using these examinations.

“In patients with substantial cerebral oedema [swelling of the brain], prediction of outcome on the basis of standard clinical examination and structural brain imaging is probably little better than flipping a coin,” writes Jamie Sleigh from the University of Auckland, New Zealand, and Catherine Warnaby from the University of Oxford, UK, in a linked Comment.

The study assessed whether two new functional brain imaging techniques - PET with the imaging agent fluorodeoxyglucose (FDG) and functional MRI (fMRI) during mental imagery tasks - could distinguish between vegetative and MCS in 126 patients with severe brain injury (81 in a MCS, 41 in a VS, and four with locked-in syndrome - a behaviourally unresponsive but conscious control group) referred to the University Hospital of Liége, in Belgium, from across Europe.

The researchers then compared their results with the well-established standardised Coma Recovery Scale-Revised (CSR-R) behavioural test, considered the most validated and sensitive method for discriminating very low awareness.

Overall, FDG-PET was better than fMRI in distinguishing conscious from unconscious patients.

Mental imagery fMRI was less sensitive at diagnosis of a MCS than FDG-PET (45 percent vs 93 percent), and had less agreement with behavioural CRS-R scores than FDG-PET (63 percent vs 85 percent). FDG-PET was about 74 percent accurate in predicting the extent of recovery within the next year, compared with 56 percent for fMRI. Importantly, a third of the 36 patients diagnosed as behaviourally unresponsive on the CSR-R test who were scanned with FDG-PET showed brain activity consistent with the presence of some consciousness. Nine patients in this group subsequently recovered a reasonable level of consciousness.

- MNT