Commentary

The finding that leisure time intellectual activity can significantly reduce the risk of dementia in people over the age of 75 years¹ lends credence to the possibility that CST might be effective in people with established dementia. The study by Spector et al provides evidence that CST in the form of reality orientation can significantly increase performance on selected neuropsychological tests. Even a small, 4 point decline in the Alzheimer’s Disease Assessment Scale–Cognition among patients with mild to moderate Alzheimer’s disease has been associated with a 35% increase in the odds of becoming dependent.² Activity-of-daily-living dependency from cognitive impairment is a major determinant of the time required to care for nursing home residents.³

Spector et al do not report the characteristics of patients who benefited from CST or the domains of cognitive function that were most likely to improve. It is unclear how much of the observed improvement occurred in orientation, which makes up 10 of 30 points on the MMSE and 8 of 70 points on the ADAS-Cog. Notably, staff ratings of personal care and behaviour—clinically relevant correlates of cognition—deteriorated similarly in the 2 groups.

Social and cultural factors, as well as systems of healthcare financing, will probably determine how well CST can be disseminated. Senior day care centres represent an ideal setting for CST, but their use varies substantially among ethnic groups in the US.⁴

Further studies of the costs and benefits of CST are needed before its widespread adoption can be recommended.