| Author(s): | Annette Bauera; Martin Knappa; Adelina Comas-Herreraa; Danielle Guyb; |
|---|---|
| Institution(s): | a Care Policy and Evaluation Centre, London School of Economics and Political Science; |
| Production date: | April 2019 |
| Last reviewed: | June 2023 |
| Last updated: | June 2023 |
| Acknowledgements: | We are grateful to the ESSENCE project advisory group (in particular Dr Aija Kettunen, Research and Development Services for Social and Health Economics, Diaconia University of Applied Sciences, Pieksämäki, Finland) for their helpful comments on an earlier draft of this case summary. We thank Elisa Aguirre and Martin Orrell for their help in preparation of an earlier summary prepared for NHS England and for the Modelling the Outcome and Cost Impacts of Interventions for Dementia Tooklit. |
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Dementia is among the leading causes of mortality in high-income countries such as England, but there is currently no cure. Alongside symptomatic medication, therapeutic interventions can support people with dementia to better cope with memory loss and other symptoms, which can improve their quality of life. Cognitive stimulation therapy is one of the most researched interventions for people with dementia and has consistently shown promising results. In fact, guidelines from the National Institute for Health and Care Excellence (NICE) recommend offering group cognitive stimulation therapy.
The Prime Minister’s Challenge on Dementia 20201 set out a strategy for improving access to diagnosis, assessment and support for people with dementia, such as cognitive stimulation therapy (CST). The National Institute for Health and Care Excellence and Social Care Institute for Excellence guidelines2 recommend CST for people with mild–to-moderate dementia. Cognitive stimulation therapy is seen as part of the solution to address this challenge. However, overall provision is still patchy across the country.
This case summary presents economic evidence from two randomised controlled trials and an economic modelling study carried out by the National Institute of Health and Care Excellence (NICE) on CST and maintenance CST, as well as findings from a scaling-up study with projections to 2040.
Cognitive stimulation therapy involves 14 sessions, twice a week over 7 weeks. It typically consists of structured 45-minute group therapy sessions involving themed activities. Members give their group a name, and each session has the same structure to ensure continuity. For example, sessions typically include a warm-up activity, a song and a ‘reality orientation board’ at the beginning of every session. This board has information on the group and details including date, time, place and weather. Sessions cover a range of activities to stimulate thinking, memory and to connect with others such as by:
The sessions are designed to be relaxed, fun and to create opportunities for people to learn, express their views and work with others in a sociable setting. A training manual and DVD have been developed with guidance on how to plan and run the sessions and different ways to check progress.3 The manual has been translated and adapted for a number of other cultures and countries.4
There is a maintenance programme of CST that can be followed after the initial 7 weeks of the cognitive stimulation programme. This is referred to as maintenance CST, which involves an additional 24 weekly sessions that follow the same structure and principles as the cognitive stimulation programme.
CST can improve the memory and thinking skills of people with mild-to-moderate dementia and possibly improve their quality of life.5-8 Some carers and relatives of people with dementia report that people with dementia show improvements in language and the willingness to join in conversations.9
A randomised control trial (RCT) evaluated CST6 for people with dementia living in care homes. The study found that CST worked as well as standard anti-dementia medication. Another RCT,7 in which half the people with dementia were living in the community and the other half in care homes, found that CST had benefits for people in addition to those from the anti-dementia medication they were taking.
Maintenance CST has also been evaluated in randomised controlled trial. All people in the study had already participated in the original 14 sessions of CST and were now participating in the additional 24 sessions. This study showed that maintenance CST helped improve the quality of life of participants. It also showed that maintenance CST improves cognition for people on dementia medication. However, for those not on medication there were no additional improvements in cognition over and above the improvements already made during the original 14 sessions of CST.
When asked for their views on the cognitive stimulation programme,8 people with dementia who took part in the group sessions thought:
People with dementia also reported that improvements in concentration and memory. They also felt that the action of talking in the group helped them to remember. One participant claimed:
‘It always makes a change when you have to concentrate on something it’s more helpful for your memory. … I think it makes you concentrate more in everything you’re doing really.’
An economic evaluation of CST10 (carried out alongside the previously mentioned RCT6) found that there was a high probability that CST is cost-effective.10 Whilst health and social care costs for people who received CST were slightly higher than for the usual care group (about £2010), improvements in cognition and quality of life were large enough to suggest that the intervention was good value of money: The cost of achieving a 1-point difference in cognition (measured by Mini–Mental State Examination was £90, and the cost of achieving a 1-point difference in quality of life (measured by the Quality of Life in Alzheimer’s Disease) was £27 (both costs inflated to today’s prices). The cost of providing CST averaged £238 per individual over the 7-week period (£30 per week).
NICE conducted – as part of their guideline for dementia interventions – an economic analysis of CST using modelling techniques.1 They concluded that the intervention had a 50% to 70% probability of being cost-effective: CST achieved a benefit of 0.033 quality-adjusted life years compared to standard care, at an additional cost of £653. The resulting cost-effectiveness ratio was just under £20,000 per QALY – so this means at the lower end of the cost per QALY thresholds that NICE typically applies (which ranges from £20,000-£30,000). The modelling was based on outcomes data from their own meta-analysis of different randomised control trial studies, and their cost data were based on data from an economic evaluation.9 In their study they assumed a cost of providing CST of £653 per individual, which is much above the one used the single economic evaluation.
There is also economic evidence on maintenance CST. An economic evaluation (carried out alongside the previously mentioned randomised control trial)11 found maintenance CST was likely to be cost-effective when looking at self-rated quality of life as the main outcome. In addition, it was likely to be cost-effective for those on dementia medication when cognition was the main outcome. The combination of anti-dementia medication and maintenance CST was more cost-effective than medication alone. This was according to number of indicators, including cost per QALY. In terms of change in health and social care use and costs, those were slightly lower for the maintenance CST group (about £134 over 6 months) compared to the usual care group. However, the difference was not statistically significant. The cost of maintenance CST averaged £634 per individual over the 6-month period (£24 per week).
In summary, both CST and maintenance CST are likely to be cost-effective for people with mild-to-moderate dementia; this is particularly so if those are offered in combination with dementia medication.
A recent microsimulation study, largely using information on the costs and effectiveness of CST presented above and combining it with projections of numbers of people with dementia in England, found that scaling-up CST for people with incident dementia can improve health-related quality of life in a cost-effective manner.12 Adding maintenance CST improves health-related quality of life even more but the economic evidence is less compelling since there is no evidence that MCST is generating savings elsewhere. As expenditure and cost of unpaid care rise, cost per QALY for CST would increase from £12,596 in 2015 to £19,573 whereas cost per QALY for CST and MCST combined would grow from £19,853 in 2015 to £30,906. Overall, scaling up the implementation of CST for eligible people is estimated to cost £19.1 million in 2020, which includes expenditure minus savings to health and social care in other parts of the system. Investing in MCST requires £35 million and there would be no savings elsewhere.
Unpaid care costs increase when CST and MCST is scaled. Providing CST is also staff-intensive and there are therefore questions whether there are models of care by which the interventions can be integrated into routine care. Considering that CST is one of the very few non-pharmacological interventions known to improve health or quality of life whilst being cost-effective, exploring best and affordable ways of scaling-up CST and MCST would be beneficial.
There can be challenges when evaluating interventions for this population, which need to be taken into account when interpreting findings. For example, it is not easy to develop outcome measures that can be completed by people with severe dementia symptoms and that produce reliable results. Partly in an attempt to address this challenge, studies often use a range of outcome measures, which can make it difficult to compare findings between studies, or to come to final conclusions about whether an intervention is effective or cost-effective.
There have also been challenges in understanding how differences in outcomes measured with clinical scales translate into meaningful changes for people with dementia as this is likely to vary between individuals. In addition, studies to date have not included a longer-term perspective to assess outcomes and costs.
These challenges suggest that it is important to use some caution in interpreting findings.
The importance of addressing the dementia challenge in practice is well recognised. At the 2013 G8 Dementia Summit13, health and science ministers called for “greater innovation to improve the quality of life for people with dementia and their carers while reducing emotional and financial burden.” Likewise, the Prime Minister’s Challenge on Dementia 202015 set out a strategy for improving access to diagnosis, assessment and support for people with dementia, such as CST.
CST is seen as part of the solution to address this challenge. Recently, there has been a large scaling up of CST in memory clinics – it is thought that 80% of UK memory services currently offer CST.14 In addition, around 2-3% of care homes currently offer the intervention. A small number of day and community centres offer CST as well.
In practice, CST is often implemented as part of routine activities, rather than a full course programme. As such, costs of providing CST are most likely lower than those estimated in cost-effectiveness studies, but implementation of a ‘lighter’ version of CST might also reduce its effectiveness. . Considering that unpaid care costs rise as CST is being scaled, suggesting an increased burden for carers, it is important to understand whether some additional support should be provided for carers alongside the delivery of CST.
The team who developed cognitive stimulation therapy in England have links to a selection of NHS Trusts offering the programme on their website.15
Martin Knapp (m.knapp@lse.ac.uk), London School of Economics and Political Science.
NIHR School for
Social Care Research
