The Implementation of Cognitive Stimulation Therapy Hong Kong Version (CST-HK) for Promoting Cognitive Functioning and Psychosocial Well-being of People With Dementia
Phase: NA
Conditions: Dementia of Alzheimer Type
Sponsor: The University of Hong Kong

 
1 
The Implementation of Cognitive Stimulation Therapy Hong Kong Version (CST-HK) 
for Promoting Cognitive Functioning and Psychosocial Well-being of People with 
Dementia 
 
Research Protocol  
12 February 2018 
 
 
Investigators 
Gloria Hoi Yan WONG 
Assistant Professor 
Department of Social Work and Social Administration 
The University of Hong Kong 
Email: ghywong@hku.hk 
Tel: (852) 3917 2074 
 
Yui Ching CHUNG 
Physiotherapist 
Elderly Service Department 
Hong Kong Young Women’s Christian Association 
 
Wai Chi CHAN 
Clinical Associate Professor 
Department of Psychiatry 
The University of Hong Kong 
 
Yan ZHANG 
PhD Candidate 
Department of Social Work and Social Administration 
The University of Hong Kong 
 
 
 
 

 
2 
Background 
Dementia is a group of disorders characterized by cognitive impairments that affect a person’s 
everyday functional ability, causing disability and poor quality of life. It affects 46.8 million 
people worldwide in 2015, and the number is expected to reach 74.7 million in 2030 and 131.5 
million in 2050 (Prince et al., 2015). The World Health Organization has announced it as a 
public health priority since 2012 (World Health Organization, 2012). In Hong Kong, the 
number of people with dementia is projected to increase two-fold from 103,433 in 2009 to 
332,688 in 2039 (Yu et al., 2012). There is currently no cure for the condition. 
  
Non-pharmacological interventions such as cognitive training, cognitive rehabilitation, and 
cognitive stimulation aim at slowing down the cognitive decline experienced by a person with 
dementia (Bahar‐Fuchs, Clare, & Woods, 2013). Cognitive stimulation involves a range of 
group activities and discussions to enhance general cognitive and social functioning. A meta-
analysis of 15 studies with a total of 718 persons with dementia showed evidence of benefits 
of cognitive stimulation on cognitive function, quality of life, and self-reported well-being of 
the people with dementia (Orrell et al., 2017). The benefits appeared to add on to medication 
effects (Aguirre, Woods, Spector, & Orrell, 2013). The clinical improvements in verbal and 
visual memory, orientation, and auditory comprehension after cognitive stimulation appeared 
to be able to translate into improvements in real world activity (Hall, Orrell, Stott, & Spector, 
2013), as seen in enhancement of the communication and social interaction of persons with 
dementia (Woods, Aguirre, Spector, & Orrell, 2012).  
 
In view of the current evidence, cognitive stimulation is recommended by the National Institute 
for Health and Clinical Excellence and the Alzheimer's Disease International as an evidence-
based, non-pharmacological intervention to be offered to all people with mild-to-moderate 
dementia (National Institute for Health and Clinical Excellence [NICE], 2007; Prince, 
Bryce, & Ferri, 2011). A standard protocol of cognitive stimulation therapy with evidence is a 
7-week intervention developed by Spector and her colleagues (Spector et al., 2003). It is a 
series of standardized, well-structured stimulating activities, implemented in a sensitive, 
respectful and person-centered manner. Group CST typically involves 14 sessions of 45-minute 
group activities that required cognitive processing delivered over a 7-week period (2 sessions 
per week, with approximately 45 mins per session) (Aimee Spector et al., 2003). The group 
size was standardized to be 6 to 8 persons (Orrell et al., 2017). People with dementia would 
participate in each of the 14 designated theme activities during each session. The activities 
aimed at stimulating and engaging persons with dementia in an active way, and providing an 
optimal learning environment and the positive social benefits of group therapy (National 
Institute for Health and Clinical Excellence [NICE], 2007). Cognitive stimulation therapy 
can be delivered by non-specialist healthcare workers with minimum training (Khan, Corbett, 
& Ballard, 2014; Paddick, 2015; Aimee Spector et al., 2003). This allows CST to be used in 
low-resource environment (Paddick, 2015). Manuals in different languages had been published 
for the group leaders to follow. Due to this advantage of high reproducibility with high quality 
evidence support, CST was widely adopted in over 20 countries (Orrell et al., 2017).  
In Hong Kong, there is currently no recommendations or routine provision of cognitive 
stimulation. In 2015, the standard group CST protocol was culturally adapted for and tested in 
Chinese people with dementia in Hong Kong (CST-HK) (Wong et al., 2017). The observed 
improvements in cognitive outcome was in line with that of overseas studies (Hall et al., 2013; 
Aimee Spector, Orrell, & Woods, 2010). The protocol appeared to be feasible and acceptable 

 
3 
to Hong Kong Chinese, with high attendance rate (92%) and low attrition rate (13%). Cultural 
issues identified in the pilot have been published and recommendations were made in adapting 
the protocol to the Hong Kong cultural settings (Wong et al., 2017). A Hong Kong Chinese 
version of the manual for CST group leaders has been published in 2017 (Spector, Thorgrimsen, 
Woods, & Orrell, 2017).  
 
This healthcare promotion project aims to enhance the quality of life and cognition of people 
with mild-to-moderate cognitive impairment through the use of CST-HK delivered by trained 
non-professional group leaders. As part of project evaluation, we aim to test the effectiveness 
of CST-HK compared with a wait-list control group who will receive care as usual during the 
waiting period.  
 
Research Objectives  
The research aims to investigate the effectiveness of CST-HK among people with mild-to-
moderate cognitive impairment in Hong Kong in a larger scale across service settings. We also 
aim to explore the effectiveness of CST-HK delivered by non-professional staff, as a possible 
solution to address the shortage of specialized healthcare manpower and increasing demands 
of non-pharmacological interventions for people with dementia.  
 
Hypotheses 
We hypothesized that, compared with the wait-list control group, the group who have received 
a 7-week (14-session) CST-HK intervention delivered by trained non-professional staff will 
show greater improvement or maintenance of (1) quality of life; and (2) cognitive performance. 
 
Research Design  
This is a cluster randomized wait-list control study.  
 
Study Sample 
A total of 128 older persons with mild to moderate cognitive impairment will be recruited from 
nine service units of Hong Kong Young Women’s Christian Association, including two 
residential care units and seven community care units. This sample size is calculated based on 
the primary outcomes of quality of life and cognitive function. Repeated measure analysis of 
variance (ANOVA), between factors will be used. Assuming a medium effect size (f = 0.25), 
80% power and 5% significance level, with two groups and two time points (calculated using 
G*Power 3.1.9.2), a total of 98 participants are required. We propose a sample size of 128 to 
accommodate for a 30% attrition rate. 
 
Inclusion and exclusion criteria are:  
• 
A clinical diagnosis of mild-to-moderate dementia, or a cognitive assessment result 
suggestive of mild-to-moderate cognitive impairment; 
• 
Be able to communicate and understand Cantonese;    
• 
Be able to hear and see well enough to participate in the cognitive stimulation activities; 
• 
No major illness that would affect participation (including clinically significant depressive 
symptoms or acute psychotic disorders); 
• 
No behavioural problems (e.g., aggression, inappropriate sexual behaviors) or psychotic 
symptoms (e.g., hallucination, delusion) that would interfere with participation in the 
intervention; 
• 
A caregiver who is able to give joint informed consent. 
 
 
 

 
4 
Intervention and Procedures 
A briefing session will be provided to participants and their family caregivers by the staff of 
Hong Kong Young Women’s Christian Association for recruitment. Upon giving written 
consent, participants will be randomized into intervention group (n=64) or waitlist control 
group (n=64) in groups of eight. Two randomization lists will be generated by HKU researchers, 
one each for residential care units and community care units. Hong Kong Young Women’s 
Christian Association will be informed about the group allocation upon successful recruitment 
of eight eligible participants. The intervention group will receive the14-session group CST-HK 
(45 minutes per session, two times a week, for 7 weeks in total) provided by trained facilitators. 
The wait-list control group will receive usual care in the service units they are attach to and 
will start their CST-HK programme after an 8-week delay.   
 
A total of 40 CST-HK facilitators without specialized healthcare background will be recruited 
by Hong Kong Young Women’s Christian Association. They are required to attend two 4-hour 
workshops to acquire the knowledge and skills for delivering CST-HK. The knowledge and 
skills include the guiding principles, and the theme of each training session. After the 
workshops, the facilitators will be designated to nine elderly service units mentioned above 
and practice their learnt knowledge and skills in delivering CST-HK under the supervision of 
experienced CST-HK interventionists with specialized healthcare background in Hong Kong 
Young Women’s Christian Association. At the end of the practicum, the trainees will be 
evaluated to ensure the fidelity of CST-HK.  
 
The person with dementia and their caregivers will undergo an interview at study baseline and 
7 weeks. A service assistant blind to the group allocation will conduct the interviews. The 
interview will last for approximately 45 minutes for the person with dementia and the caregiver, 
respectively. A post-intervention assessment will be conducted in the wait-list control group 
upon completion of the delayed intervention. 
 
Measurements for Primary Outcomes  
The primary outcome of CST-HK, quality of life, will be measured using the Quality of Life 
in Alzheimer's Disease scale (Chan, Chu, Lee, Li, & Yu, 2011; Logsdon, Gibbons, McCurry, 
& Teri, 2002). Self-rating of the persons with dementia would be used in this study using the 
patient version of this tool.  
 
Cognitive function will be measured using the Alzheimer's Disease Assessment Scale-
Cognitive Subscale test (Chu et al., 2000). No deterioration in cognition is defined as a change 
in the score of ≥0 point in ADAS-Cog, and clinically meaningful improvement a change in 
score of ≥4 points, in the post-intervention assessment compared with baseline score.  
 
Data Analysis 
Intention-to-treat analysis will be conducted. For the main outcome measures of quality of life 
and cognition, ANOVA will be used to assess changes from baseline to 7 weeks after between 
the intervention group and the wait-list control group. Further analysis will be conducted by 
ANCOVA controlling for baseline differences in age, gender, education level, type of care 
setting, AChEI use (using random effects) and baseline cognition and quality of life. As a 
sensitivity analysis, we will also conduct exploratory analysis including the post-intervention 
data from the wait-list control group. 
 
 
 

 
5 
References 
Aguirre, E., Woods, R. T., Spector, A., & Orrell, M. (2013). Cognitive stimulation for dementia: a systematic 
review of the evidence of effectiveness from randomised controlled trials. Ageing research reviews, 12(1), 
253-262.  
Bahar‐Fuchs, A., Clare, L., & Woods, B. (2013). Cognitive training and cognitive rehabilitation for mild to 
moderate Alzheimer's disease and vascular dementia. The Cochrane Library.  
Chan, I. W. P., Chu, L. W., Lee, P. W., Li, S. W., & Yu, K. K. (2011). Effects of cognitive function and depressive 
mood on the quality of life in Chinese Alzheimer's disease patients in Hong Kong. Geriatrics & 
gerontology international, 11(1), 69-76.  
Chu, L., Chiu, K., Hui, S., Yu, G., Tsui, W., & Lee, P. (2000). The reliability and validity of the Alzheimer's 
Disease Assessment Scale Cognitive Subscale (ADAS-Cog) among the elderly Chinese in Hong Kong. 
Annals of the Academy of Medicine, Singapore, 29(4), 474-485.  
Hall, L., Orrell, M., Stott, J., & Spector, A. (2013). Cognitive stimulation therapy (CST): neuropsychological 
mechanisms of change. International psychogeriatrics, 25(3), 479-489.  
Khan, Z., Corbett, A., & Ballard, C. (2014). Cognitive stimulation therapy: training, maintenance and 
implementation in clinical trials. Pragmatic and observational research, 5, 15.  
Logsdon, R. G., Gibbons, L. E., McCurry, S. M., & Teri, L. (2002). Assessing quality of life in older adults with 
cognitive impairment. Psychosomatic medicine, 64(3), 510-519.  
National Institute for Health and Clinical Excellence (2007). Dementia: supporting people with dementia and 
their carers in health and social care. NICE clinical guideline 42, London: National Institute for Health 
and Clinical Excellence.  
Orrell, M., Hoe, J., Charlesworth, G., Russell, I., Challis, D., Moniz-Cook, E., Aguirre, E. (2017). Support at 
home: interventions to enhance life in dementia (SHIELD)–evidence, development and evaluation of 
complex interventions. Southampton (UK): NIHR Journals Library. 
Paddick, S.-M. (2015). Cognitive stimulation therapy as a low-resource intervention for dementia in sub-saharan 
africa: Initial results of a controlled trial. Alzheimer's & Dementia: The Journal of the Alzheimer's 
Association, 11(7), P607.  
Prince, M., Bryce, R., & Ferri, C. (2011). World Alzheimer Report 2011: The benefits of early diagnosis and 
intervention. Alzheimer’s Disease International (ADI). 
Prince, M., Wimo, A., Guerchet, M., Ali, G., Wu, Y., & Prina, M. (2015). World Alzheimer Report 2015—The 
Global Impact of Dementia: An analysis of prevalence, incidence, cost and trends. Alzheimer’s Disease 
International (ADI).  
Spector, A., Orrell, M., & Woods, B. (2010). Cognitive Stimulation Therapy (CST): effects on different areas of 
cognitive function for people with dementia. International Journal of Geriatric Psychiatry, 25(12), 1253-
1258.  
Spector, A., Thorgrimsen, L., Woods, B., & Orrell, M. (2017). Making a difference: An evidence-based group 
program to offer cognitive stimulation therapy (CST) to people with dementia; the manual for group 
leaders (text in chinese). Hong Kong: Hong Kong University Press. 
Spector, A., Thorgrimsen, L., Woods, B., Royan, L., Davies, S., Butterworth, M., & Orrell, M. (2003). Efficacy 
of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised 
controlled trial. The British Journal of Psychiatry, 183(3), 248-254.  
World Health Organization (2012). Dementia: a public health priority. World Health Organization. 
Wong, G. H., Yek, O. P., Zhang, A. Y., Lum, T., & Spector, A. (2017). Cultural adaptation of cognitive stimulation 
therapy (CST) for Chinese people with dementia: multicentre pilot study. International Journal of 
Geriatric Psychiatry.  
Woods, B., Aguirre, E., Spector, A. E., & Orrell, M. (2012). Cognitive stimulation to improve cognitive 
functioning in people with dementia. The Cochrane Library.  
Yu, R., Chau, P. H., McGhee, S. M., Cheung, W. L., Chan, K. C., Cheung, S. H., & Woo, J. (2012). Trends in 
prevalence and mortality of dementia in elderly Hong Kong population: projections, disease burden, and 
implications for long-term care. International Journal of Alzheimer’s Disease.