Cognitive Stimulation Therapy for older people with Dementia in Africa: A Scoping Review [version 1; peer review: awaiting peer review]

Background: Cognitive Stimulation Therapy (CST) is a non-pharmacological intervention developed for dementia that is useful in Africa but has not been studied widely. We reviewed the existing evidence regarding CST among older people living with dementia in Africa. Methods: A systematic literature search on CST among older people with dementia in Africa from 2000-2021 was done in MEDLINE (PubMed), CINAHL (EBSCOhost), and PsycINFO. A narrative approach was taken to chart, synthesize and interpret the data using Microsoft Excel. Results: After removing duplicates using Endnote, a total of 122 studies were retained and screened first by title, then abstract, and finally by full text. Seven articles matched the inclusion/exclusion criteria. CST has been adapted and piloted in two African countries (Nigeria and Tanzania). CST studies in Africa indicate improvements in clinical outcomes including cognition and quality of life. Although there are some barriers to overcome, CST has significant facilitators in an African context. Conclusions: CST is feasible, adaptable, and acceptable in the African countries it has been implemented in. Some cultural barriers, such as religious affiliation and respect for older people, should be overcome. Further research is needed to further evaluate the efficacy of CST in various African contexts.


Introduction
Globally, about 9% of the population is aged 65 years and older and is estimated to increase to 17% by 2050 1,2 . In sub-Saharan Africa (SSA), adults aged 60 years and older are projected to increase to 670 million by 2030. By 2050, 10% of the population in Africa will be aged 60 years or older [3][4][5] . Older persons experience multimorbidity from non-communicable diseases 5 . One such condition is dementia, which affects the brain and causes a progressive decline in cognition and behavioural systems 6,7 . Alzheimer's disease, the most common type of dementia contributes to 60-70% of the new cases 7,8 .
Risk factors for dementia among older people include age, sex, low education, hypertension, stroke, poor socioeconomic status, and vascular disease 12 . Others are diabetes, tobacco use, obesity, harmful alcohol use, physical inactivity, depression, and social isolation 8 , and recently, HIV 13,14 . Dementia has several physical, psychological, social, and economic impacts 15, 16 , including a decline in cognition, quality of life, and functions needed to maintain independence 8,15 . This places additional burden on caregivers 8, 11,[15][16][17][18] .
Management of dementia is twofold: pharmacological treatments and non-pharmacological or psychosocial interventions 19 . Pharmacological treatments delay the progression of the disease. Conversely, psychosocial interventions improve cognition and quality of life and reduce caregivers' burden 18 . Cognitive Stimulation Therapy (CST) is an evidence-based non-pharmacological intervention developed for dementia 9 . CST is recognised as a cost-effective non-pharmacological intervention for dementia among older people 17,20 , and regarded as a "gold standard", evidence-based treatment 21 . CST is chosen for it is less costly to implement especially in resource limited settings including Africa. CST may be implemented and beneficial in the African context because it is cost-effective, helps caregivers, reduces having to rely on medications that may not be accessible to many patients especially in rural areas. Developers of the intervention aim for it to be used internationally [22][23][24] . It was adapted for Africa in 2016 25 , and has been piloted in Tanzania, and Nigeria 23,[26][27][28] . CST is a groupbased psychosocial intervention for people with mild to moderate dementia 23,[29][30][31][32] . It consists of 14 sessions of 45-60 minutes duration each, occurring twice a week for 7 weeks 29,33 .
The rationale of this study is that despite the evidence of CST's efficacy, there is limited evidence of data on its applicability to older persons (age 50 years and older) with dementia in Africa. There is a need to describe the barriers, facilitators, and impact of CST on older persons' quality of life. In addition, describing the adaptability, feasibility, and acceptability of CST in Africa was warranted.
Therefore, the objectives of this study were to review the literature on CST among older people with dementia and Africa in order to investigate: 1) study designs related to CST; 2) Adaptations/modifications in CST delivery in Africa; 3) barriers and facilitators to implementing CST within African contexts. To answer these questions, a scoping review was conducted. The rationale is that we aimed to: identify the types of available evidence, clarify key concepts/ definitions in the literature, examine how research is conducted on a CST, identify key characteristics or factors related to CST, act as a precursor to a systematic review and to identify and analyse gaps in the knowledge base 34 .

Design, protocol and registration
We conducted a scoping review of CST among older persons in Africa. We focused on studies that administered the original version of the CST 29,31,32 . The 14 sessions of CST include physical games, sound, childhood, food, current affairs, faces/senses, word association, being creative, categorizing objects, orientation, using money, number and word games, and team quiz 25,29,32 .
Our study population was older people (age 50 years and older) living with dementia and the intervention was CST. The WHO recommends that for African countries, we define older persons as those with 50 years and older 35 . Several studies from the IN-DEPTH network have used this definition in their studies [36][37][38][39] . The outcomes for the scoping review included: improvement in cognition, quality of life, and activities of daily living.

Eligibility criteria
The inclusion criteria were papers which reported studies of CST; participants were older people (age 50 years and older) with dementia in Africa; papers were peer-reviewed and were published in English and were in the timeline of between 2000 and 2021.
Papers were excluded if they focused on animals; reported studies solely conducted outside of Africa; were not published in peer-reviewed journals; reported physiological interventions, invasive procedures, medicines, or procedures that are not connected to CST.

Information sources
A systematic literature search on CST among older people with dementia in Africa from 2000 to 2021 was conducted for MEDLINE (via PubMed), CINAHL (via EBSCOhost), and PsycINFO (via EBSCOhost) 40 . The databases searched were based on two previous studies 7,40 . Internationally recognized principles for searching, screening, and appraising results and for conducting a scoping review were followed 41 . Table 1 presents the databases searched in February and March 2021. Search terms were adapted and refined from previous reviews 6,7,9,42,43 and by consensus between the authors (SOW and ED). Search terms included cognitive stimulation therapy (CST), dementia, and Africa. The search terms were combined using Boolean Operators (OR, AND). Table 2 presents    the full search strategy for the scoping review. The search terms used to identify African nations were adapted from another study 44 . The adaptation involved removing the "tw" ("(text word" search searching in title and abstract fields) from the search terms, as this field search restricted results 45 .

Selection of sources of evidence
Relevant studies were identified by searching electronic databases, reference lists, and key journals, and consulting Prof. Spector, lead developer of CST 46 . The databases searched were based on two previous studies 7, 40 : MEDLINE (via PubMed), CINAHL (via EBSCOhost), and PsycINFO (via EBSCOhost) 40 .
Reference lists of identified studies were searched to identify additional studies. Searches were limited to English between 2000-2021. Articles were selected using the set inclusion and exclusion criteria 46 .
Study sampling and screening process resulted into a creation of a separate Endnote file was for each database (CINAHL=43, MEDLINE=113, and PsycINFO =42). The studies (n=198) were then collated and after removing duplicates, a total of 122 studies were retained and reported in the PRISMA Flow Diagram ( Figure 1, Table 3) and checklist for Scoping Reviews (PRISMA-ScR): https://zenodo.org/record/7957420.
Titles and abstracts were screened for inclusion. Two articles were excluded at this stage 47,48 . Full texts for remaining studies were then reviewed. The articles were reviewed by 2 independent reviewers. Decisions on inclusion were made independently and uncertainties were discussed by the authors.

Data charting process and data items
Data charting process included weekly meetings were held to discuss and review the data charting form captured in Microsoft Excel 46 . Table 4 shows the data extraction template.
The data items or variables extracted included the following: author(s); year of publication; study location (country); title; aims of the study; study design; study methodology; study populations or participants; outcome measure; and key results and recommendations 46 . Table 5 presents the description of the studies. No quality assessment was undertaken 46 . Thematic data analysis and synthesis followed the data charting stage to ensure further processing and categorisation 46 . We identified the key themes emerging from the results sections of the qualitative articles 6 . Results were then collated, summarized, and reported following the reporting standards for scoping reviews 49 .

Selection of sources of evidence
Following the screening process seven articles were included in the scoping review ( Table 5). Papers that were excluded focused on children, targeted animal populations such as mice and rats, and others focused on other geographical locations rather than Africa, or on other forms of cognitive training such as computerized approaches, while others were invasive procedures ( Figure 1). Table 5 presents the characteristics of the included studies. The seven included studies covered only two African countries: Nigeria and Tanzania 9,22,23,25-28 . Two teams based in West Africa (Nigeria) or East Africa (Tanzania) conducted the studies.

Description and characteristics of the studies
The designs of the included studies varied. Two studies were quantitative. One was a randomized study with a steppedwedge design 26 , while the other had no control group 27 . Two   25,28 . One study was a study protocol yet to be implemented 23 . One study was a systematic review of psychosocial interventions for dementia in low-and middle-income countries 9 . Another study was an implementation study 22 .
Six studies took place in Tanzania  The studies recruited older participants (age 65 years and older) and their sample sizes varied from 9 27 to 50 participants 23 .
One study reported a sample size of 16 participants aged 70 years and older and 4 group facilitators 28 . One study did not report sample size 25 . Another study reported a sample size of 34 but did not specify how many participants were people with dementia and how many were carers 26 .

Adaptability of CST to Africa
CST was adaptable to cultures in Africa [25][26][27][28] . In India, a translated CST was acceptable 50 . In Brazil, adaptations were made for CST with great success 51 . The group sessions are highly relevant to the communal lifestyle and extended family systems in many African settings.
Cultural adaptation is a key element of the CST 22,25 . The adaptation process includes translation into local languages and the use of group facilitators -specialist staff such as nurses, doctors, and occupational therapists who are trained to facilitate the group sessions 22,23,25 . CST was first adapted for use in Africa (CST-SSA) in 2016 25 , following a recognized method of adapting psychotherapeutic interventions 20 . The CST-SSA was piloted in Tanzania and Nigeria 23,26-28 , which resulted in recommendations for further refinement and modification 25 .
There is now a published protocol for international use of CST (CST-International) 22,23 .
Generally, the initial adaptation of CST, CST-SSA maintained the 14 sessions of the original CST 25,29 . Recommended adaptations included the identification of suitable treatment settings, task adaptation to accommodate illiteracy, awareness of cultural differences, and use of locally available materials and equipment to ensure sustainability 25 . Further adaptation included the use of local current affairs and village news in the fifth (current affairs) session, local maps instead of national maps for the tenth (orientation) session and using local materials and equipment for the task adaptation session 23 .
In CST-International 23 , the number of sessions is maintained -14 sessions over 7 weeks using a manual. For task adaptation, the use of local materials and equipment is recommended. CST-International recommend selecting a meeting place acceptable to all. Places of worship are recommended to be avoided as these may cause acceptability challenges for those from other denominations or religions. Conducting two sessions on the same day is strongly recommended to reduce travel time. However, CST-International is still a protocol and its implementation has not yet been evaluated 23 .
CST is highly adaptable for the African context and is highly acceptable by the population including participants and caregivers in Nigeria and Tanzania 9,25-27 .
The key assessment of feasibility in the CST studies was the overall attendance rate. Generally, the adapted CST-SSA was feasible in Africa 9,25-28 . Transportation reimbursement ($2) assured participants returned for sessions. Giving a small gift to older people to take to grandchildren was quite motivating 25 . CST-SSA can be delivered by non-specialist staff 27 .

Acceptability of CST in Africa
CST intervention was acceptable to participants and caregivers. Group sessions appeared very therapeutic for older people 27 . Missing sessions were due to memory deterioration, transport and logistical challenges, illness, and family events 26 . In one Nigerian study, no one dropped out of the entire course -11 sessions had full attendance and three sessions had eight people in attendance (98%). In the Hai district of Tanzania, 5 participants completed the program and two dropped out while in Lalupon, Nigeria 25 . Attrition rates were higher in Nigeria than in Tanzania. To increase acceptability, selecting a meeting place acceptable to all helps 23,25 .
The cost per participant per complete course was 34 USD. The cost of the CST intervention, assuming 14 sessions per intervention and eight participants per group were 268 USD per session. The mean costs or expenditure for formal healthcare by the patients was low ($1.18) 26 . Even though it appears affordable, most people would not afford it without financial support.

Content, delivery and implementation of CST in Africa
Being with others during group sessions is a key aspect of the CST. Groups are recommended to be composed of between 5-8 people 9,22,25,26 . People with dementia are encouraged to reflect, concentrate, and engage their memories through the practical and outdoor activities held in each session. These should take place in a relaxed environment. 22,25,28 . This is beneficial for the African context -i.e. helps with isolation of elderly people and isolation is a risk factor for dementia. Table 6 shows the key outcomes and measures for their effectiveness. The assessment tools used in the 7 articles are categorized into several themes: feasibility 9,25-28 , adaptability, acceptability, barriers, and facilitators of CST implementation and clinical outcomes 22,23,26 . The most used outcomes were cognition and quality of life 9,26-28 . Other outcomes were caregiver burden, and activities of daily living (ADLs). Other outcomes of the studies included disability measured by the WHO Disability Assessment Schedule (WHODAS), Neuropsychiatric Inventory (NPI), and Hospital Anxiety and Depression Scale (HADS). Several clinical outcomes were reported 9,25-28 . There were only three studies that were quantitative and reported clinical outcomes [25][26][27] (Table 4).

Outcomes of CST in Africa
The first trial of CST in SSA reported cognitive improvement post CST intervention regarding new learning and memory (ADAS-Cog mean scores changed from 15.5 to 11.4). There was a reduction in behavioral and psychological symptoms of dementia (BPS) and caregiver burden 26 after completion of the course. A Nigerian study reported that cognition improved (ADAS-Cog from 32.0 to 22.7) during pre-CST and post-CST respectively 27 . A systematic review found evidence for improving cognition due to CST 9 . A qualitative study in Tanzania reported mental stimulation after group activities and improvement in cognition and memory but did not report statistical outcomes 25,28 . Therefore, cognitive improvement is a key outcome of the CST.
Quality of life has been reported to improve with CST intervention 9,25-27 . Several systematic reviews have reported a strong association between CST and the quality of life 6,7,42 . However, some RCT found no significant association between CST and quality of life in Portugal 21 . A Nigerian study reported an improvement in quality of life (a change of 89% as measured by WHOQOL-Bref) 27 . A systematic review similarly reported improvement in the quality of life as well 9 . Therefore, in African contexts, CST improves quality of life.
Significant improvements in activities of daily living (ADL), neuropsychiatric behaviors, and caregiver burden were reported. For example, in one Nigerian study, the Zarit Burden Inventory (ZBI) score decreased (suggesting improvement) from 18 to 11 27 . In Tanzania, there was an improvement in the neuropsychiatric symptom burden, number, and severity as measured by the Neuropsychiatric Inventory (NPI) 26 .

Barriers of CST implementation in Africa
Some studies highlighted the barriers of CST implementation 22,28 . These challenges include: Group conflicts arising from previous challenges over land ownership and fears of gossip. Other causes of group conflicts included tribal and religious differences in Tanzania 28 . This was connected to the selection of venues for the meeting as places of faith 26 . In addition, oversharing personal information bred conflicts 22,25 .
The shortage of qualified professionals and specialized healthcare workers (such as occupational therapists, nurses, and doctors) was viewed as a key barrier 22,25 . CST was viewed as additional work for both healthcare professionals and caregivers. Non-medical personnel can be trained to deliver the CST.
Facilitator-provider language barrier was noted 28 . The lack of awareness about dementia among the participants and their caregivers and the lack of understanding about psychosocial interventions including CST among people with dementia were further barriers 25,27 .
Low literacy attainment among the participants affected some sessions. The orientation session could not use maps since many participants were unable to read and write 22 . Tasks involving holding a pen and reading words were not appropriate for older persons not accustomed to writing 25 .
Poor transportation and infrastructural challenges limited travel to group sessions 22 . Seasonal roads and rainy seasons complicated travel to venues for meetings. Transportation difficulties increased travel time and inflated travel costs 25 .
Resource constraints and logistical challenges limited the sessions' smooth running. 25 . Some sessions needed equipment that required electricity, which was unavailable. The privacy of location settings was critical but was difficult to achieve in some settings 22 .
Cultural considerations limited CST's impact as older people are expected to be relieved of household chores and duties. This contradicts CST principles of encouragement of mentally stimulating activities. Another cultural issue identified in Tanzania was the confusion over the names of participants 25 .
Lifestyle and work arrangements posed challenges for CST in rural areas that prioritized village events such as burials and weddings 25 . Some older people tended to miss sessions in favour of these events. Contingency plans were required for those who miss sessions 9,25 .
There was a general preference for tangible medical treatment instead of psychological interventions, the. rational for which was not understood by all 9 . Morbidity due to non-communicable diseases in old age made offering non-pharmacological interventions difficult as some participants expected medical treatment for their health conditions 25 . The critical issue surrounding multimorbidity and the unmet need for healthcare among older persons and their preference for pharmacological treatment is cross-cutting in most studies [25][26][27][28] . A CST study in Brazil also reported poor motivation for CST due to expectations in medical treatment 51 . Therefore, for CST to be successful, managing such expectations is flagged as a critical component of the intervention.
Finally, visual impairments without eye care among some older people limited their engagement with CST, screening for CST should include a brief eye exam 22 . Despite these barriers, some of them may be able to be overcome by addressing them in different ways as indicated below.

Facilitators of CST in Africa
Several facilitators for CST-Africa were identified. First, caregiver engagement motivated participation 23 . Engaging caregivers reduced their boredom and the psychological anxiety of waiting during sessions. Second, group sessions were highly motivating for older persons. Being around others distracted many participants from physical illness 9,26,28 . Many participants were able to work together and remind each other of good memories 28 . Third, medical check-ups for blood pressure and appropriate referrals motivated participant engagement in both Nigeria and Tanzania 25,28 . Fourth, CST-SSA can be delivered by trained personnel 27,28 . Fifth, positive group experiences such as shared memories, group cohesion, and personal development motivated many older persons with dementia 28 . Participants often look forward to attending the next group sessions due to the created sense of belonging 28 . Finally, the provision of transportation and refreshments was an important incentive for participation in the CST group sessions.

Strengths and limitations
This is the first scoping review to be conducted specifically about CST for older persons with dementia in Africa. Methodologically there was consensus from two researchers which increased the reliability of data charting 46 . Some studies reported adequate sample sizes which provided a rich data 28 . This scoping review has provided a comprehensive overview of CST-SSA implementation. The review used a systematic and reproducible search strategy using a scoping review framework 46 .
Several limitations merit discussion. We limited this review to articles published in English hence excluding Francophone Africa 43 . Some studies report a limitation of asking people with dementia to detail experiences in the past, as recall is likely to be limited 28 . Translation to address language barriers could have introduced some nuances of translation and interpretation 28 . Due to limits of time, we were unable to include grey literature.

Recommendations
Our recommendations consider CST implementation in African nations, future practice, and research.

CST implementation in Africa
CST is important in Africa over other options for therapy that may be available (pharmacological treatment, other treatments) because it is cost-effective and can be delivered by trained non-medical personnel. It is aligned to the group therapy which supports the extended family system in Africa.
Having synthesised the findings of all seven papers we suggest that the intervention is delivered in two sessions on the same day each week to reduce travel time for older persons and their carers 23,25 . In addition, contingency plans to reschedule sessions missed due to village events would be beneficial 25 . Delivering the intervention on village market days should be avoided wherever possible.
Dementia awareness courses for family carers should highlight the stigma associated with dementia 22 . Selecting a meeting place acceptable and neutral to all, avoiding places of worship, such as village offices or halls is important 23,25 , as is support from village committees is critical for success 25 .
Refreshments for group sessions are key for older people 22,23,25 . Also, it is good to give participants a small gift, such as confectionary, to give to a grandchild, following attendance 25 . To deal with expectations of medical treatment and to be ethical, blood pressure screening and appropriate referral by nursing staff are important 25,28 .

Implications for practice
In the future, CST implementation in African nations should include groups of the same tribe or religion, achieve a gender balance, and provide refreshments 28 .
Training local people as facilitators who understand cultural dialects could improve the acceptance of the CST 28 . Group facilitators are to manage medical expectations on the part of the participants 25 .

Implications for future research
Future research should include high quality studies of effectiveness of CST in African countries to test its effectiveness in the improvement of cognition and quality of life. To date, only one RCT of CST has been conducted, in Tanzania 26 . Developing research proposals to pilot the CST-SSA is warranted 27 .

Conclusions
CST is feasible and has been adapted to African contexts and piloted in two African countries (Nigeria and Tanzania).
Although there are some barriers to overcome, CST has the potential to make a significant impact, by improving the quality of life, and reducing the burden for the carers of older persons living with dementia in Africa. Finally, CST improves clinical outcomes including cognition and quality of life among older persons.
The next steps include implementing a study to estimate the prevalence of dementia among older persons in Uganda (2023-2026). This is needed as preliminary data for piloting and implementing the CST intervention study among older people with dementia in Uganda (2028-2032).

Informed consent statement
Not Applicable

Ethics approval and consent to participate
The study is based on secondary data. Ethical approval was not required.