The wellbeing potential of Cognitive Stimulation Therapy for people living with dementia involving object handling

MASC essay. Written 2023. Assessment was to write a chapter for an academic book (hence the reference to this being a "chapter")

Within this chapter I explore the potential of Cognitive Stimulation Therapy (CST) and museum object handling interventions to improve the overall wellbeing of people living with dementia. In part one, I discuss CST and the varying ways it can be used to aid people living with dementias’ cognition. In part two, I investigate object handling and how it can improve wellbeing through sensory engagement. In part three, I look at how creating an interdisciplinary approach involving both CST and object handling could create better wellbeing outcomes for participants. Additionally I discuss the steps required to complete this interdisciplinary approach to cognitive stimulation therapy. Finally, I conclude this chapter, discussing the future of CST and object handling.

It is important to define some key terms used within this chapter. Firstly, dementia is described within the medical community as an umbrella term which covers more than 100 different conditions that affect the brain cells, causing a loss of cognitive function and ability (Rahman and Howard, 2018:20). Dementia is currently on the rise. It is estimated at the time of writing that around 55 million people live with dementia worldwide and that number increases by around 10 million each year (WHO, 2021). There is currently no cure for dementia and researchers are investigating if it is possible to slow the cognitive decline associated with dementia through a variety of interventions. I will discuss this idea later on in this chapter.

Secondly, object handling is an intervention that involves using objects from museums and taking them into healthcare settings (e.g. a hospital or a care home) (Thomson and Chatterjee, 2014). Object handling is frequently used with people living with dementia because it engages participants in a variety of sensory ways. Researchers noted that this sensory engagement “can assist older people to organise and integrate information from different senses, leading to multiple encoding of information processing, which in turn can facilitate new learning” (D’Andrea, et al. 2022). This concept from object handling has been theorised to increase short term memory function for people living with dementia and allow participants to recall memories more reliably (see Camic et al, 2017). Object handling falls into the wider arts in health discipline of “object-based wellbeing”, a term coined by Thomas Kador and Helen Chatterjee, which describes the process of engaging with handling objects to improve wellbeing (2021). This is derived from the arts in health discipline object based learning, which is typically used with students and “describe[s] multisensory engagement with museum collections for the acquisition and dissemination of subject specific and cross disciplinary knowledge, observational, practical and other transferable skills” (Kador and Chatterjee, 2021:01).

Finally, cognitive stimulation is an “intervention for people with dementia that offers a range of enjoyable activities providing general stimulation for thinking, concentration and memory” (Thomason, 2012). There are many creative ways to engage participants in cognitively stimulating activities. Arts activities are often used, painting, listening to music and performance arts are a few examples of cognitively stimulating activities the arts can provide (DementiaUK, 2021). In 1994, a more science based approach to cognitive stimulation was created; Cognitive Stimulation Therapy. This intervention is a “brief, evidence-based treatment for people with mild to moderate dementia [...] Sessions aim to actively stimulate and engage people with dementia, whilst providing an optimal learning environment and the social benefits of a group” (Cognitive Stimulation Therapy, 2019). At the time of writing, CST is only offered to someone once they have received an official diagnosis of dementia and is arguably; therefore, a more medically driven discipline being linked to the disciplines of psychology and dementia studies respectively (see Comas-Herrera and Knapp, 2016 and Cognitive Stimulation Therapy, 2023). 

I now go on to explore how CST and object handling interventions can help to prevent cognitive decline in people living with dementia, as well as improve their wellbeing. Before moving onto exploring the potential to combine both disciplines to create an interdisciplinary approach to dementia care.

Part One: What is Cognitive Stimulation Therapy?

As previously mentioned one intervention that is currently being used (and shows potential to slow the decline in cognition for people living with dementia) is cognitive stimulation based interventions. There are many different cognitive stimulation based interventions but CST tends to be the most commonly used. Researchers have conflicting opinions on whether CST is effective or not. This is largely due to the wide variety of CST interventions and the training levels of those running the sessions. CST interventions are typically formed of 14, two hour weekly sessions. Each week will have a different ‘theme’, from childhood, to food and drinks and the conversations will be centred around said theme. This framework stays the same regardless of whether the intervention is individual or group based. No museum objects are handled in the sessions, but there are frequently art based or conversation based activities for participants to engage with (MODEM, 2016).

There are two main CST set ups: individual sessions (ICST) and group sessions. Additionally, both can be short term interventions or longer term interventions - which is typically called Maintenance CST (Gibbor et al, 2020). Both group and ICST sessions involve the same principle of using engaging activities (normally arts based) to provide cognitive stimulation to the participant/s. It is also important to note that all CST interventions are only used with participants who have mild to moderate dementia (Werheid et al, 2020). ICST differs from group CST sessions, as instead of a trained dementia professional leading the sessions, the caregiver/s for the person living with dementia facilitate the one-on-one CST session. However, group sessions of CST tend to be preferred to individual sessions, as a group setting tends to have better outcomes for cognition (Spector et al, 2010). Despite group sessions having better cognitive outcomes, barriers can prevent the easy access to group CST sessions. Dickinson et al noted that group sessions typically require a trained facilitator who has knowledge in both dementia and the specific requirements of CST sessions. This can prevent staff in care homes or community settings from feeling confident to facilitate the intervention (2017). Individual CST sessions are therefore easier for staff to prescribe and facilitate. In 2017, researchers undertook a randomised control trial to evaluate whether ICST sessions achieved their claims of decreasing the speed of cognitive decline. Orrell et al found that individual CST sessions did not achieve the desired outcome, but did have a marked improvement in the quality of life and overall wellbeing for both the caregiver and the person living with dementia (2017).

In addition to the participant setting (i.e. group or individual), location is also important for wellbeing outcomes. A 2012 study found that participants living with dementia were more likely to benefit more from CST interventions if they were in a care home, than if they were still living within their home community (Aguirre et al). Furthermore, female identifying participants had better outcomes than male identifying participants. This has been noted in other studies as well (see Woods et al, 2006). It has also been argued by researchers that CST is favourable to more medicalised interventions, as it is less invasive and has limited to no side effects, which medication cannot compete with (Coen et al, 2011). However, due to the nature of dementia, and the fact that cognitive decline continues to happen regardless of interventions, many studies have noted that despite CST interventions showing wellbeing improvements in the short term, longitudinally, the wellbeing effects do not last. Instead, researchers suggest that a stable cognitive function is a more realistic long term outcome for CST interventions (Spector et al, 2010, Orfanos et al, 2020 and Bertrand et al, 2022).

Part two: What is Object Handling?

In addition to CST interventions, researchers have also noted the benefits museum based object handling can have for participants living with dementia. Museums are fairly new to socially prescribed activities, with the first recorded project taking place in 2014 but they are well placed within communities to offer non-clinical wellbeing based interventions at a low cost (Thomson et al, 2018). Object handling is one such intervention. It can be used to start discussions around wellbeing, history, nature and more. Additionally it has been noted to have positive wellbeing effects on patients living with dementia (see Camic et al, 2017, Chatterjee and Camic, 2015 and Thomson and Chatterjee, 2014). Interventions in museum spaces that involve object handling have been noted to improve self reported levels of wellbeing and self confidence in participants (Camic et al, 2021). Camic and colleagues also noted that this increase in wellbeing happened in both community and care home settings and the participants specifically took part in object handling interventions in small groups (2021). This arguably means there is scope to include object handling into the already existing CST framework. Another study found that object handling could be used with people living with dementia as a “means of improving well-being, mood, and social inclusion” (D’Andrea et al, 2022).

In their book Object-Based Learning and Well-being, Kador and Chatterjee discussed the various ways object handling ties into wellbeing across the lifespan. They noted that when participants handle objects “they are fully immersed, emotionally, cognitively and physically [...] [which can lead to] confidence building, leadership, navigating emotional and pedagogical thresholds, as well as problem solving” (2021:05). These points have been directly linked to an increase in wellbeing for participants by researchers (see Letrondo et al, 2023 and Rahman and Howard, 2018). In their report on object handling for wellbeing, Thomson and Chatterjee noted object handling can reduce anxiety and distress for participants (2014). This reduction in anxiety and distress is theorised to be because of the cognitive stimulation that typically occurs in these settings. Cognitive stimulation can decrease the likelihood of a co-occurring dementia related condition called delirium, which can cause patients to hallucinate and increase morbidity and mortality rates in older adults (Rahman and Howard, 2018:43). Similarly to CST interventions, researchers have also noted that wellbeing improvements do not stay stable long term after an intervention has ended (Camic et al, 2021 and D’Andrea et al, 2022).

Part Three: What would an interdisciplinary cognitive stimulation therapy approach look like?

Combining CST interventions with museum object handling has not been sufficiently studied and lacks any significant research looking at the benefits of combining both disciplines. However, it is clear there is scope to combine both interventions to create an engaging, supportive, cognitively stimulating interdisciplinary approach to CST. CST interventions already have a set up that would easily enable the incorporation of museum object handling - the themes of each session would provide instructions for museum staff to choose objects related to the theme. Additionally, creating an interdisciplinary approach to CST would arguably increase the wellbeing potentials for participants as both CST and object-based wellbeing interventions have been proven to have a significant positive impact on participants overall wellbeing and quality of life.

There is currently only one project that has created an interdisciplinary approach to cognitive stimulation therapy. The Victoria and Albert Museum (V&A) in London UK has already started investigating the possibilities this interdisciplinary approach to CST interventions could hold for participants (see Tucker, 2022). Having only undertaken two full 14 week CST interventions, the V&A states their dataset is too small to draw conclusive results from but states participants have engaged well with their sessions (Tucker, 2022). However, they are currently running their third iteration of the project and I am engaging with participants and the clinical team to evaluate the efficacy of the sessions. This active engagement gives me a unique insight into how interdisciplinary CST sessions involving museum object handling could work. As well as being interdisciplinary in its approach, this project with the V&A also has a transdisciplinary approach to running the project, working within museum spaces and using clinical teams for diagnostic criteria, curators from the museum and fully trained CST facilitators to create the best possible environment for participants to engage with the intervention. Without the multiple teams collaborating together, this interdisciplinary approach to the CST project would not be possible. CST interventions need clinical input and museum based object handling is not suitable to be undertaken without the support of curators from museums.

Working in an interdisciplinary way within the broader scope of not only arts in health but arts for dementia, would enable practitioners to find new and innovative ways to improve the health and wellbeing of their participants. It is clear from the discussions held in this chapter that there is a need for further research investigating the potentials of combining CST and object handling. Both disciplines have been shown to improve wellbeing; however, in order to combine them, true co-production and collaboration are required between the arts and sciences. If future projects were to take this new interdisciplinary approach to cognitive stimulation therapy, there are several important things to consider:

Firstly, the engagement with the objects. One challenge of working with museum objects is the age and fragility of many of them. Ceramics and many other objects cannot be readily handled by the public due to the preservation of the object preventing this (National Museums Scotland, 2007). This lack of engagement with objects could reduce the positive impact for participants engaging in the object handling intervention, so creative ways are required to work around this limitation. For example, recreations of ceramic objects could be used in place of the real thing, allowing participants to see and interact with the object without any risk to the real object.

Secondly, as previously mentioned, CST interventions require training and when working within museums, it is important that all staff involved in the project understand how to work with people living with dementia and the importance of the CST intervention.

Thirdly, the evaluation of the project is key to understanding the enablers and disablers of accessing and engaging in a more interdisciplinary approach to cognitive stimulation therapy. Many researchers have noted a lack of qualitative data and studies around CST and object handling interventions and while quantitative data is important to study the wellbeing improvements, often quantitative data does not tell the entire story and can even clash with qualitative data (see Bertrand et al, 2022, Camic et a., 2021, Aguirre et al, 2012 and Coen et al, 2011). This conflict brings up a wider debate over how we evaluate and judge project datasets based on a scientific approach. Science allows no scope for personal reflection but it is the ‘gold standard’ of evaluations, with randomised control trials (RCTs) being widely thought of as the best way to prove (or disprove) an intervention works (Hariton and Locascio, 2018). There is a valid argument that RCTs always leave people who could benefit from the arts intervention out, as a control group is required (Cartwright, 2007). Cartwright also argues that “gold [standard] methods are whatever methods will provide a) the information you need, b) reliably, c) from what you can do and from what you can know on the occasion” (2007). For an arts-based interdisciplinary CST intervention, the aforementioned CST and object handling research agrees that the ‘gold standard’ would be a combination of qualitative and quantitative data.

With dementia on the rise and numerous new innovative ways suggested to combat cognitive decline, CST and object handling are frequently used as individual disciplines. Throughout this chapter the research has shown they individually have good results for improving people living with dementias’ overall wellbeing state in the short term. This chapter has explored the scope to combine CST and object handling and argued that this interdisciplinary approach would create a unique object-based wellbeing intervention that actively promotes better cognition for participants, as well as provide much needed sensory engagement within the CST framework. Daisy Fancourt suggests that “if the arts are carefully and appropriately applied, they can be a powerful tool for supporting health” (2017:41). However, in order to fully support the health and wellbeing of people living with dementia, the understanding around researching interventions needs to change and museums need to consider which objects and which staff are suitable for a CST intervention. With new creative projects appearing all the time, and museums like the V&A actively seeking ways to incorporate CST into their object handling sessions, the future for arts-based dementia interventions had potential to embrace the interdisciplinary approach to create a positive impact for its participants. 

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