Designing the programme

The underlying basis of the programme stemmed from the RO systematic review, which suggested significant benefits in both cognition and behaviour following RO for dementia sufferers. However, the results of the RO review were strongly weighted by the study of Breuil et al (1994), the largest trial with the most significant results. Activities in sessions included connecting dots to form pictures of common objects, drawing common objects from different perspectives, associated words, and naming and categorising objects. The author arranged to meet the neuropsychologist who supervised this trial and observe the ongoing ‘cognitive stimulation’ groups. The Broca Hospital in Paris had set up a service for people who had recently been diagnosed with dementia at the memory clinic. These people attended twice weekly groups with the aim of maintaining their memory, and allowing them to function in the community for as long as possible.

AUTHORS, INTERVENTION, QUALITY/DETAILS

DESCRIPTION (TREATMENT GROUP) OUTCOME FOLLOWING TREATMENT

RO / Randomised Controlled Trials

Baines et al (1987) 15Ps (RO=5, RT=5, C=5)

RO board, old & current newspapers, personal & local photos, materials to stimulate all senses (eg. Cinnamon, silk, honey).

Sig. Improvement in behaviour. Positive trends in cognition and communication.

Positive effects reported by staff. Breuil et al (1994)

Blind RCT, 56 Ps (CS=29, C=27)

Copying pictures, associated words, naming & categorizing objects.

Sig. Improvement in cognition.

Gerber et al (1991) 24Ps (R0=8, SC=8, C=8)

Simple exercises, s e l f - c a r e ,preparation, orientation. Room with RO board, large clock, coloured illustrations.

Sig. Improvement in orientation & language in both RO & social interaction groups.

Goldstein et al (1982) 14Ps (R0=7, C=7)

Reading RO board, naming people, use of RO questionnaire (eg. day, month season, etc.)

Sig. Improvement in orientation. No change in ADL.

Hanley et al (1981) 57 Ps (R0=28,C=29)

RO board, clocks, calendars, maps & posters. Room overlooked garden area to enable discussion.

Sig improvement in verbal orientation in response to basic orientation items. No change in behaviour. Hogstel (1979)

44Ps (RO=22, C=22)

Introductions, reading RO board, tell time, discuss lunch menu. Patients had large clock & calendar in bedrooms. Additional input from staff outside RO class.

No change in degree of confusion.

Observations: RO patients became more co­ operative, and began communicating much more with each other.

Voekel (1978)

20 Ps (RO=10, SS=10)

Greeting, touching, RO board, calendars, clocks, antiques. Simple activities, eg. Identifying pictures.

No change in mental status following RO. Sig. Improvement in SS group.

Wallis et al (1983) 38 Ps (R0=18, C=20)

Repetition o f orientation information (eg. time, place, weather).Oasrt&, pictures, touching objects & material.

INTERVENTION, QUALITY/DETAILS Woods (1979)

14Ps (RO=5, ST=5, C=4)

Daily personal diary, group activities (dominoes, spelling, bingo). Naming objects, reading RO board.

Sig. improvement in memory, learning, information & orientation in RO group.

RO: Controlled Trials / Other

Barnes (1974)

ABA, 6 Ps, No statistics

RO board, calendar, maps. Discussed names, lunch menu, etc.

Positive trend in questionnaire which showed learning and behavioural change.

Citrin & Dixon (1977) CT, 25 Ps (R0=12, C=13)

Personal & environmental information presented individually, 24 hr RO.

Sig. Improvement in RO Information sheet. Geriatric Rating Scale was inconclusive. Coen Mieli et al (1991)

CT. No. of Ps & method of allocation unknown.

Space & time orientation, memory prompting, naming objects & body parts, training cognitive, semantic & phonetic abilities.

Positive trend in cognition. Patients became less passive.

Increase in effort & ability to concentrate. Combleth & Combleth (1979)

ABA, 22Ps

RO board, copying, telling time, counting money. Sig. improvement in orientation and ADL. Gotestam (1987)

ABA, 5Ps

Time Orientation: diary, clock. Person Orientation: name games. Room Orientation: maps and

nameplates on walls.

Sig. improvements in time and room orientation, insig. improvement in person orientation.

Greene (1979); RO ABA, 3Ps, No statistics

“Personal Orientation Questionnaire” for each person. (Time, place, current affairs, family, friends, history)

Improvement in orientation, generalising to other areas of behaviour.

Reeve & Ivison (1985) CT, 20 Ps (RO=10, C=10)

Classroom & 24 hour RO (environmental symbols, signposts, clocks & 2 RO boards)

Sig. improvements in cognition and behaviour.

Zanetti et al (1995) CT, 28 Ps (RO=16, C=12)

Early classes: personal, time & space orientation

Later: historical events, famous people, attention,

memory & visuospatial exercises.

Sig. improvement in verbal abilities. No changes in other cognitive functions or disability measures. No changes in self-rated depression scores.

INTERVENTION, QUALITY/DETAILS RTj Memory Techniques, VT Baines et al (1987); RT RCT, 15 Ps (RT=5. R0=5, C=5)

Old photos (local scenes, personal), books, magazines, newspapers, domestic articles.

Negative trend in information /orientation after RT. Positive trend in behaviour. Positive staff reports, eg. got to know people better.

Bourgeois (1990); Memory training

ABA, 3Ps

Developed prosthetic memory aids: plastic wallets containing information of personal relevance (photos, daily schedule, etc.)

Content & quality of conversation doubled or tripled, using Likert ratings.

Goldwasser et al (1987); RT RCT, 30 Ps (RT=10, SS=10, C=10)

Topics', food, family, personal artefacts, songs, music, celebrations.

Positive trend in cognition. Increased depression. No change in behaviour.

Kiemat(1990);RT, ABA, 23 Ps

Topics in chronological sequence. Multisensory materials, pictures, recordings, historical items.

Positive qualitative results. E.g. people initially only responded to direct questions from staff, later to questions from other residents without prompts. Koh et al (1994); CS. CT, quasi

randomised, 30 Ps (15=CS, 15=0

Basic elements of RO, RT and remotivation. Weekly discussion topics e.g. money, hobbies, pets, fruit and festivals. Stimulated all senses.

Sig. Improvements in mental state score.

Orten et al (1989); RT RCT, 56 Ps (RT=28, C=28)

Structured topics, covering life-span. Pictures & memorabilia discouraged.

Insig. improvement in social behaviour. Group differences attributed to experience of leaders. Quayhagen & Quayhagen

(1989); Cognitive stimulation given on one-to-one basis by caregivers. Non-randomised.

Communication exercises: conversation skills, facts, opinion, etc; memory-provoking techniques: verbal & non-verbal; problem-solving exercises: planning / categorization.

Qualitative findings reported by caregivers:

inçroved emotional status of patients, maintenance over time in aspects of cognitive functioning. No improvement in carer well-being.

Toseland et al (1997); VT RCT, single blind, 88 Ps (VT=31, SC=29, C=28)

Four segments, i) Warm greetings, hold hands, sing songs, ii) Focus on topic of interest, reminisce, iii) Activity, eg. poetry. Iv) Refreshments, goodbyes.

Used Feil’s Validation approach throughout.

Limited support for VT.

Staff reported reduced physically & verbally aggressive behaviour (not reported by observers). No change in medication, physical restraint or nursing time needed.

Glossary (Table 3)

RCT = Randomised Controlled Trial SC = Social Contact group

CT = Controlled Trial SS = Social Support group

ABA = Repeated measures (ABA) design ST = Social Therapy group

C = Control group CS = Cognitive Stimulation

RO = Reality Orientation group Sig. = Significant (p<0.05) RT = Reminiscence Therapy group Insig. = Insignificant

VT = Validation Therapy group Ps = Participants

Sessions began with introductions, orientation-related discussion and short-term memory prompts, such as asking people what they did the previous night or what the news headlines were. This was followed by people completing a practical task individually, which was then completed on the board by the group leader. In a session observed by the author, participants were presented with a list of (Easter) shopping and prices, and were required to calculate the cost of the entire shopping list. The hospital staff found that people attending these groups managed to maintain their functioning and live reasonably independently for longer than expected.

These groups took place in a room which resembled a classroom, with the ‘teacher’ wearing a white coat. It is important to recognise that these individuals had chosen to accept this regimented approach. Yet running similar groups in residential homes could lead to difficulties, as people are typically institutionalised, are not required to care for themselves, often lack the motivation to take part in activities, and are sometimes unaware of the extent of their cognitive decline. Even in day centres where functioning is typically higher and

people more independent, many individuals might not choose to attend groups with such explicit aims. Because the current programme was intended primarily for residential homes and some day centres, a more indirect way of using similar principles was considered in its design.

RO was the only psychological intervention for dementia that had demonstrated significant benefits following Cochrane review. Therefore, the programme was primarily designed through combining features found in the RCTs of RO that showed promising results. However, most of the trials were conducted in the late 1970’s and 1980’s, and the content and format might be considered somewhat ‘out of date’. Since then, there have been advances in the understanding of strategies which might be used to result in cognitive improvement. This has coincided with criticism of RO, mainly when it may have been applied in a rigid, uncaring and insensitive manner. More modem approaches which stem from the earlier RO work might be described as ‘cognitive stimulation’ (Quayhagen and Quayhagen, 1989; Breuil et al, 1994). This programme was designed using some of the ideas of the early RO studies, but might be considered more akin to the cognitive stimulation work of the 1990’s.

The team designing the programme included two clinical psychologists, Steve Davies and Bob Woods, who had extensive experience in running groups for people with dementia. There has been strong circumstantial and clinical support for the subjective benefits of RT, primarily that people enjoy it, and that it increases interaction and engagement (Woods, 1996; Gibson, 1993). Therefore it was felt that three sessions encouraging long-term

memories would complement the programme, even though the results of the RT review were inconclusive. Although the research on Validation Therapy provided no empirical evidence of its effectiveness, validation as an approach which encourages sensitivity and warmth, through empathie listening, eye contact and validating peoples communication and behaviour; was utilised in the programme whenever possible.

The elements of individual studies which were incorporated into the programme are highlighted in italics in table 3. These were drawn primarily from RCTs with positive results. The initial programme consisted of seventeen, forty-five minute sessions in four phases: 1) The senses, 2) Remembering who you are, 3) Remembering people and objects, 4) Everyday practical issues. Sessions began by welcoming the group, singing the ‘theme song’ and consuming tea and biscuits, before the activity took place. At the end of sessions, the discussion and ideas were summarised, the theme song sung again, and the group said its farewells.