“Besides medication, what else can be done?” This is a question that almost every family of an older person with dementia asks. The answer often lies in everyday company. The care workers in our home nursing service, under the guidance of an occupational therapist, keep the older person company through a series of structured cognitive activities, including reminiscence picture cards, cognitive activity books, mazes, sensory mystery bags, playing cards and jigsaws, reality orientation discussion and music activities. These are not simply to “pass the time”. They correspond to two psychosocial approaches supported by international evidence: cognitive stimulation therapy (CST) and reminiscence therapy.
Our team states the size of the training effect plainly. The real value of cognitive training is not to “reverse dementia”. It is that, through safe activities with an evidence base, it can keep up cognitive ability and support mood and social contact, so the older person is no longer sitting idle all day. The sections below first make clear how large the real effect of training is, and then describe the types of activity that care workers carry out in daily company.
The aim of cognitive training is to maintain the older person’s abilities, mood and quality of life. It cannot reverse dementia and cannot take the place of medication. Research shows that the effect of this training is small to moderate and short-term, and that each person responds differently. The best approach is therefore to keep practising, together with regular follow-up and drug treatment.
Clinical evidence on cognitive training for older people with dementia
Views on “playing games to train the brain” tend to go to two extremes. Some see it as a cure-all, and others think it is just a way of passing time. Clinical evidence falls in between: training does bring a real but modest benefit. The two most commonly used methods above have both been tested in Cochrane systematic reviews, which also confirm that they are safe (no negative effects reported), though the size of the effect differs between them.
In other words, these activities are safe and worth doing, and they encourage everyday exchange, but they should not be expected to make the condition improve a great deal. A landmark randomised controlled study (Spector et al., 2003) even found that this manual-guided CST improved cognitive test scores by an amount “comparable to trials of dementia drugs”. It is still a small, short-term benefit, and the ideal is for it to run alongside medication and medical follow-up, and not to replace them.
Cognitive training also helps the older person’s mood, which is less often noticed. A research team at The Chinese University of Hong Kong pooled 36 randomised controlled studies (2,551 people) and found that cognitive training clearly reduces low mood, with the Geriatric Depression Scale (GDS-15) score falling by about 1.3 points on average. The effect was clearer for cognitive stimulation therapy and computerised training. The study was carried out by a local university and used assessment scales commonly used in Hong Kong, which makes it a credible reference.
Six types of cognitive activity that care workers usually carry out
Under the guidance of an occupational therapist, care workers most often build the six types of activity below into daily company. Each type follows a CST or reminiscence therapy format, and its difficulty can be adjusted flexibly to the older person’s ability and interests.
Reminiscence picture cards
- Old Hong Kong pictures: looking at photos of Hong Kong in the past brings back the older person’s memories and starts conversation
- Festival and tradition cards: talking about traditional customs at festivals stimulates long-term memory
- Matching everyday objects: practising recognising and sorting objects usually seen
Cognitive activity books
- Number joining: joining numbers in order to practise attention and sequence memory
- Spot the difference: comparing two pictures to train observation and visual discrimination
- Word filling: helps to maintain language and reading ability
Maze games
- Paper mazes: finding a way through a maze on paper to train spatial sense and problem solving
- Gradual difficulty: starting easy and slowly adjusting difficulty according to the older person’s performance
- Planning: practising thinking ahead and planning a route
Sensory mystery bags
- Touch recognition: guessing what an object is by feel alone, without looking into the bag
- Sensory stimulation: touching with the hands stimulates the sense of touch and makes the older person more alert
- Multisensory involvement: remembering how the object feels and then describing it in words
Playing cards and jigsaws
- Card matching: turning over cards to exercise short-term memory
- Sorting and simple card games: playing simple card games to train attention and strategy
- Jigsaws: train spatial sense and patience, and give a sense of success when finished
Reality orientation and music activities
- Reality orientation: chatting together about the day’s date, the weather and the news
- Music activities: listening to old songs to bring back memories and lift mood
- Guided conversation: following the content of the activity and chatting naturally with the older person
These six types are not separate, scattered tricks, because there is a continuous evidence base behind them. Reality orientation is the historical forerunner of CST (the Cochrane report states clearly that CST comes from reality orientation training). Reminiscence cards and old songs are the media most often used in reminiscence therapy. Sensory mystery bags echo the multisensory involvement that CST emphasises. Card games and jigsaws, which have a social element, suit the strongest part of the CST evidence: encouraging communication and social interaction.
Three benefits of cognitive training
Turning the clinical evidence above into daily care, cognitive training support can bring benefits in three areas. The wording used here is deliberately “may help” and not “improves” or “reverses”, because research shows that the effect is small to moderate, short-term and varies from person to person.
Cognitive function
- Helps to maintain memory and attention (studies show CST helps slightly)
- Structured repeated practice helps the older person keep existing cognitive ability
- The aim is to “maintain” existing ability, and not to “reverse” the condition
Emotional wellbeing
- May help to ease anxiety and low mood (Chan 2020)
- A sense of success after finishing an activity lifts mood a little
- More chances to communicate and interact with others (supported by high-quality CST evidence)
Daily life
- Helps to maintain everyday cognitive ability and quality of life
- Reduces the time the older person spends sitting idle all day
- Gives caregivers a structured set of activities to do together with the older person
Four key points in carrying out cognitive training
Both Cochrane and local studies point out that, for cognitive training to work, “how it is done” often matters more than “what is done”. This service is designed on the four points below.
- 1Structure and guidanceThe training programme is designed first by an occupational therapist and then carried out with the older person by a care worker, and it is not enough to hand the older person a worksheet or two to fill in. Clinical research indicates that training needs a manual, a structure and trained staff to lead it, if results are to be seen.
- 2Continued and intensiveCochrane research found that with training twice a week or more, started early at the mild (and not the moderate) stage, cognitive improvement is clearer. If it is done only once or twice now and then, the effect is very limited.
- 3Difficulty adjusted for the individualPractice that is too hard discourages the older person, and practice that is too easy gives no stimulation. The care worker watches the older person’s alertness and performance that day, and adjusts the difficulty of the cards, books and games flexibly.
- 4Regular reports, alongside professionalsCare workers report the older person’s practice progress to the occupational therapist regularly, and the therapist adjusts the programme according to performance. Cognitive training also cannot replace regular medical care, and the older person should keep taking medication and attending follow-up appointments.
The division of roles in our team is clear: the occupational therapist carries out the clinical assessment and designs the training programme, and the care worker keeps the older person company during practice day to day. Care workers do not carry out any cognitive assessment or diagnosis, and all of that is done by the occupational therapist. If an older person needs a professional cognitive assessment and an individual training programme, see occupational therapy for cognitive impairment.
Who it suits and safety notes
This cognitive training support suits people with dementia, people recovering from stroke, and older people who need cognitive stimulation in daily life. International research has found no negative effect on people with dementia, and the process is safe, but a few details are still worth noting before and after starting.
- The most important thing is that the older person enjoys it and is willing to take part. Do not make it feel like an examination that puts the older person under pressure
- In one-to-one practice, the care worker can better look after the older person’s mood and talk in more depth. Reminiscence activities in particular suit one-to-one
- Have the occupational therapist assess first and then hand over to the care worker to carry out the programme, which is better for both effect and safety
- Keeping up practice over the long term matters more than doing a lot in one go. Each session need not be long, but should be frequent and kept up for a long time
- If the older person is clearly in a low mood, resisting or withdrawing during practice, pause at once and talk to the therapist about how to adjust the programme