Mild to moderate dementia: cognitive stimulation and rehabilitation — a therapist's manual

This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with older people and with neurocognitive disorders, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. It makes no diagnosis: the diagnosis of a dementia and of its cause belongs to a medical and neuropsychological assessment. Diagnostic criteria are reformulated in our own words, never reproduced, and no scale item appears in it: refer to the original manuals and instruments. It is not written for the people concerned or for those close to them. Confusion of sudden onset, abuse or suicidal thoughts call for an immediate response: contact a doctor or your country's emergency services.

1. The programme at a glance

Indication. A person with mild to moderate dementia, due to one of the most common causes, those included in the trials (Alzheimer's disease, vascular damage or a mixed form; the other causes are presented in section 3), who lives at home or in a care home, who can follow a group conversation or an hour-long interview, and who agrees to take part. The programme is addressed to them, and not to their carer: work with the carer is the subject of another manual on this site, Neurocognitive disorders: supporting the person and the carer — a therapist's manual.

Reference model. Two psychological interventions whose effectiveness has been established by controlled trials, and which British guidelines place first at this stage (National Institute for Health and Care Excellence, 2018). The first is group cognitive stimulation, that is, varied and enjoyable activities, carried out in a small group, which exercise thinking, language and memory in a social setting (Spector et al., 2003; Woods et al., 2023). The second is individual goal-oriented cognitive rehabilitation, that is, work on two or three activities of daily life that the person has chosen themselves, with learning and compensation techniques adapted to their difficulties; its largest trial, the British GREAT trial, established its effect (Clare et al., 2019; Kudlicka et al., 2023). Reminiscence, which brings memories back with the help of photographs, objects or music, and the psychological treatment of anxiety and depression are added to them, where the data support them.

Format. Twenty-nine sessions in all. One assessment session (E), of 60 minutes with the person and 15 minutes with their carer; this quarter of an hour with the carer seen separately is also added to sessions R1, R10 and M4, which repeat the measures. A group module of fourteen 45-minute sessions, twice a week for seven weeks (G1 to G14), which follows the format of the original trial (Spector et al., 2003). An individual module of ten weekly one-hour sessions (R1 to R10), preferably at home, whose last fifteen minutes involve the carer. And four one-hour maintenance sessions, spread over the following six months (M1 to M4), as in the GREAT trial (Clare et al., 2019). The two modules can also be offered separately; section 16 says how.

Mechanism targeted. The programme does not seek to slow the disease, which no psychological intervention has demonstrated. It targets what does not depend on the lesions alone: withdrawal, the lack of opportunities to think and to talk, the repeated failures that make people give up, worry and sadness. The group gives back opportunities to exchange without setting anyone up to fail; the individual work relies on what the disease spares for a long time so that the person can go back to doing what matters to them.

The following table gives, for each session, what should come out of it. The measures are described in section 11.

Session	Focus	Session output
E	Assess, rule out, decide	Baseline measures, modules chosen
G1	Forming the group	Group name chosen, worksheet 1 started
G2	Time passing	The group's calendar put up
G3	Sounds and music	A musical preference stated by each person
G4	Objects and their uses	Objects sorted in two ways
G5	The places in our lives	A place described by each person
G6	Everyday numbers	A small budget drawn up together
G7	Tastes and smells	Foods sorted together
G8	Faces	Photographs compared
G9	Words	Word lists built together
G10	Doing things together, step by step	A task carried through to the end
G11	Current events	An opinion given by each person
G12	Creating	A joint piece of work
G13	Skills	A skill passed on by each person
G14	What we keep from the group	Next steps decided, worksheet 1 completed
R1	Taking stock and choosing goals	Three goals at most, rated from 0 to 10
R2	Describing a goal, building a plan	First written plan
R3	Learning without making mistakes	A piece of information or an action learned
R4	External aids	An aid set up and tried
R5	Solving a problem step by step	A solution chosen and dated
R6	Staying attentive	Two attention strategies tried
R7	Worry	A calming technique learned
R8	The activities that matter	Two activities scheduled
R9	Making what has been learned last	Practice plan up to M1
R10	Review and move to maintenance	Goals re-rated, measures repeated
M1 to M4	Maintaining	Goals re-rated, strategies adjusted

What the person takes away. Eight printable worksheets, listed in section 52: my group, my goals, my plan for a goal, my practice notebook, my story, when things are not going well, the carer's corner, my plan for what comes next. They are written in short sentences and are filled in with the person, never in their place.

What distinguishes this programme from the other manuals on this site. Three things. Its only patient is the person affected, whereas the neighbouring manual on neurocognitive disorders treats the carer first and devotes only five sessions to the person. It describes in full the two psychological interventions that guidelines offer at this stage, with a number of sessions taken from the trials that evaluated them. And it says, with evidence, what should not be offered instead, in particular repeated memory exercises presented as a treatment.

2. Before you begin

The four preliminary decisions

Has the diagnosis been made, and by whom? The programme assumes a diagnosis of dementia made by a doctor, after an assessment that looked for the reversible causes of cognitive decline. If there has not been one, the first task is to refer (section 4).

Is the stage right? The programme is aimed at mild to moderate dementia. The original cognitive stimulation trial included people whose score on the Mini-Mental State Examination (section 11) was between 10 and 24 (Spector et al., 2003), and the GREAT trial people whose score was at least 18 (Clare et al., 2019). These figures give a rough position; what decides is the ability to follow a conversation and to choose to take part.

Does the person want to come? Both modules assume that they understand what is being offered to them and that they choose to take part (Clare et al., 2013). A relative who signs them up without them is not enough.

Is there a danger or an emergency today? Acute confusion, abuse and suicidal thoughts come before the programme (section 10).

What this programme does not treat

It does not slow the disease. No psychological intervention has shown that it changes the course of a neurodegenerative disease, and promising it exposes the person and their family to a disappointment that will weigh on what follows.

It does not treat the carer. Their exhaustion, their depression, their guilt and the person's difficult behaviours belong to the manual Neurocognitive disorders: supporting the person and the carer — a therapist's manual, whose eight-session programme for the carer can be run in parallel.

It does not treat severe dementia. At that stage, interventions change in nature: sensory stimulation, comfort, care for high dependency, and support for the carer (section 4).

It does not replace legal and medical planning ahead. The mandate that designates in advance who will act for the person, advance directives on care and the designation of a representative for health decisions are prepared with the person while they still have the capacity to do so; the neighbouring manual devotes its session P5 and its section 12 to this.

Its place in relation to the neighbouring manual

The manual Neurocognitive disorders: supporting the person and the carer — a therapist's manual offers the person a short module of five sessions, numbered P1 to P5. If they have already followed them, this programme extends three of them: the aids that compensate (P2) become the individual rehabilitation module, the activities (P3) become the group module and session R8, and worry and sadness (P4) are taken up in detail at session R7 and in section 46. Session P5, on wishes for later, remains to be done if it has not been.

How to use it

Read the whole thing before the assessment session, in particular sections 3, 7, 10, 11, 43 and 44: the different dementias, the model, safety, assessment, and the two interventions in detail.

Each session is described using the same framework: the aim, the steps, what you say, the common errors, and the criterion for moving on, that is, what must be achieved before moving on to the next session.

Two warnings specific to this reason for referral.

Failure is the main risk of every session. A person with dementia is put in difficulty several times a day. A session that asks them questions they cannot answer adds one more failure, and that is how you lose them.

And the therapist can confuse activity with treatment. A pleasant workshop is not an evaluated intervention: what distinguishes cognitive stimulation from a leisure activity is a format, principles and measured follow-up (section 43).

3. The different dementias

The word dementia does not designate a disease. It designates a set of difficulties — a decline in the functions of thinking, marked enough to compromise independence in daily life (section 8) — that different diseases or lesions can produce (World Health Organization, 2026). These diseases do not affect the brain in the same place or at the same pace. They therefore do not begin with the same difficulties, do not progress in the same way and do not call for the same adjustments in session. That is why they are reviewed here, before the programme is described.

Two precautions before reading what follows. The first: diagnosing the cause belongs to a specialist doctor, a neurologist, geriatrician or psychiatrist, for example in a memory clinic. It rests on the interview, the clinical examination, the assessment of cognitive functions, blood tests, brain imaging and, when in doubt, analysis of the cerebrospinal fluid (Haute Autorité de santé, 2011, 2018). So you do not announce to the person a cause that the doctor has not retained, and you do not correct the one they have retained. The second: the descriptions that follow are typical profiles. The same disease can begin differently in a given person, and several diseases often coexist in the same person. Knowing these profiles serves two purposes: adapting the sessions to what is really affected, and spotting what does not fit the diagnosis given, so as to report it to the doctor.

Alzheimer's disease

What happens in the brain. Two kinds of lesion accumulate: deposits of a protein called beta-amyloid between the neurons, the amyloid plaques, and clumps of another protein, the tau protein, inside the neurons, the neurofibrillary tangles. This process is thought to begin many years before the first difficulties (Sperling et al., 2011). The tau lesions first appear on the inner surface of the temporal lobe, in the entorhinal cortex and the region bordering it, and then reach the hippocampus; these regions serve to record new memories. They then spread to a large part of the cortex (Braak and Braak, 1991). This progression helps to explain why the difficulty in learning new information comes first.

What you observe. The onset is insidious and the worsening gradual, over years. In the usual form, the earliest difficulty is learning and retaining new information: the person asks the same questions again, forgets a conversation from the day before, an appointment, where they put an object away. Then come difficulty finding words, disorientation in time and then in space, difficulty organising an action and, later, recognising objects or putting movements together in sequence. The person often has a poor perception of their own difficulties (section 8). There are also forms that begin with something other than memory: with language, with visual perception of space or with the organisation of action (McKhann et al., 2011).

Its place. It is the most common cause: it contributes to 60 to 70% of dementias according to the World Health Organization (2026).

What it changes in the sessions. The techniques that compensate for memory — errorless learning, spaced retrieval, external aids (section 44) — respond directly to this difficulty in learning, and they have been studied in people with this disease (Clare et al., 2010; Oren et al., 2014). Long-held skills and distant memories, preserved for a long time, are the best supports for the group as for the individual work (section 5).

Vascular dementias

What happens in the brain. They are due to damage to the blood vessels of the brain. This may be one or several strokes, sometimes only one when it affects a region that is decisive for thinking. It may also be, and this is common, diffuse damage to the small deep arteries, which gradually damages the white matter, that is, the fibres that connect the regions of the brain to one another (Sachdev et al., 2014).

What you observe. The difficulties vary according to where the lesions are, but in the foreground there is often a slowing of thought and difficulties with attention and organisation: the person takes longer to understand, to answer and to move from one task to another. Apathy and depression often accompany these difficulties. Early difficulties with walking, with small steps, with unsteadiness or falls, and frequent and urgent needs to pass urine also point towards a vascular cause (Sachdev et al., 2014). After a stroke, the onset can be sudden and the worsening can happen in steps; when damage to the small arteries predominates, the onset is gradual and the course slow, like that of a degenerative disease (Sachdev et al., 2014).

Its place. It is one of the most common causes after Alzheimer's disease, responsible for about 15% of dementias (O'Brien and Thomas, 2015).

What it changes in the sessions. Slow down: give one instruction at a time, allow time to answer and reduce the number of elements in each activity. Look for apathy and depression, which are easily taken for unwillingness (section 9). Control of blood pressure and of the other vascular risk factors belongs to the doctor.

Mixed forms

In older people, the lesions of several diseases often add up. In an American cohort of older volunteers, followed every year and who had agreed to donate their brain to research, more than half of those who had dementia showed several types of lesion at autopsy, most often those of Alzheimer's disease combined with cerebral infarcts; at the same age, people who had several lesions were clearly more often affected by dementia than those who had only one (Schneider et al., 2007). When Alzheimer's lesions and vascular lesions contribute together to the difficulties, people commonly speak of mixed dementia. The expert group that proposed the criteria for vascular cognitive disorders nevertheless considers this term ambiguous, and prefers to speak of Alzheimer's disease with vascular damage: the mixture ranges from a mainly Alzheimer's form to a mainly vascular form, and it is often difficult to say which predominates (Sachdev et al., 2014). In session, the adjustments for the two forms add up.

Lewy body dementias

What happens in the brain. A protein, alpha-synuclein, clumps together inside the neurons in inclusions called Lewy bodies, in the cortex and in deeper structures. This is the lesion of Parkinson's disease. Dementia with Lewy bodies and Parkinson's disease dementia share the same mechanisms and are now grouped together under the name of Lewy body dementias (Walker et al., 2015).

What you observe. Four features characterise dementia with Lewy bodies (McKeith et al., 2017):

• fluctuations in attention and alertness, sometimes so marked that the person seems very impaired at one moment and almost as they were before a few hours later;
• visual hallucinations that recur, often precise and detailed, showing for example people, children or animals;
• REM sleep behaviour disorder: the person acts out their dreams, talks, shouts or thrashes about while asleep, often several years before the first difficulties with thinking;
• parkinsonian signs: slowness of movement, stiffness, tremor at rest.

At the beginning, memory can be relatively spared; it is attention, the organisation of action and visual perception that are most affected (McKeith et al., 2017). Repeated falls, fainting spells, daytime sleepiness, anxiety, depression and apathy are common. Finally, these people can react severely to antipsychotic medication, which is one of the reasons why the diagnosis matters (McKeith et al., 2017).

The one-year rule. When the dementia appears before the parkinsonian signs, at the same time as them or less than a year after them, the term dementia with Lewy bodies is used. When it appears in a person whose Parkinson's disease has been established for more than a year, the term Parkinson's disease dementia is used. This boundary is arbitrary, but it remains useful in practice (McKeith et al., 2017). Parkinson's disease dementia is common: at any given time, it affects nearly 30% of people with this disease, with difficulties of attention, memory, organisation and perception of space, and often hallucinations and apathy (Emre et al., 2007).

Their place. After the age of 65, Lewy body dementias are the second cause of degenerative dementia, after Alzheimer's disease (Walker et al., 2015).

What it changes in the sessions. Schedule the sessions at the time of day when the person is most alert, and do not conclude from a bad session that the disease is getting worse: fluctuations are part of the picture. They nevertheless resemble those of acute confusion, and these people readily develop true confusion when another illness or a medication is added (McKeith et al., 2017). A change that is unusual for them, or that lasts, is therefore reported to the doctor (section 10).

Hallucinations do not always call for treatment: some people experience them without worry, or even with pleasure, while others are frightened by them (McKeith et al., 2017; Taylor et al., 2020). Do not dispute the reality of what the person sees and do not confirm it: ask them what they see and what they feel, and reassure them if they are frightened. Report to the doctor hallucinations that are new, more frequent or that distress the person; the decision on any treatment is theirs.

Use large, simple, high-contrast visual materials, and take the risk of falls into account in how the room is arranged. Non-drug approaches are recommended first in these diseases, but they have only been studied in them in isolated cases or small series (Taylor et al., 2020), and the data for this programme come mainly from Alzheimer's disease and from vascular and mixed forms (section 12). For Lewy body dementias, these adjustments are therefore clinical adaptations, not evaluated as such.

Frontotemporal dementias

What happens in the brain. Several diseases, linked to different abnormal proteins, selectively destroy the frontal and temporal lobes, which carry social behaviour, the organisation of action and language. Genetics plays an important part in them. They generally begin earlier than other dementias, most often before the age of 65, and they are among the common causes of dementia at that age (Bang et al., 2015).

The behavioural variant. It shows itself first through a change in behaviour and personality, which those close to the person sometimes sum up like this: "he's not himself any more". The person loses social restraint, with inappropriate remarks, familiarity with strangers, impulsive purchases or rash decisions. They lose initiative, appear indifferent to the feelings and needs of others, repeat the same actions, the same rituals or the same phrases, and change their eating habits, with for example a new taste for sweet things. Tests mainly show difficulties with organising action, whereas memory and perception of space are relatively spared at the beginning (Rascovsky et al., 2011). The person has little awareness of these changes. They can suggest depression, bipolar disorder or a personality disorder, but the person usually does not have the other signs of depression and often says they are not sad (Bang et al., 2015). In a series of patients from a specialist clinic, half of the people with this form had first received a psychiatric diagnosis, most often depression (Woolley et al., 2011).

Primary progressive aphasias. Here, it is language that deteriorates first, and it remains the main difficulty for the first few years (Gorno-Tempini et al., 2011; Bang et al., 2015). In the non-fluent variant, speech becomes slow, laboured and halting, with errors of grammar and pronunciation. In the semantic variant, the person speaks fluently, but loses the meaning of words: they can no longer find the names of objects and no longer understand certain single words, beginning with those they use least often. In the logopenic variant, they search for their words with many pauses and struggle to repeat a sentence; this form is most often due to Alzheimer's disease, and not to frontotemporal degeneration (Gorno-Tempini et al., 2011; Bang et al., 2015).

What it changes in the sessions. The trials of the group and of rehabilitation did not cover these forms: the GREAT trial, for example, included only people with Alzheimer's disease or a vascular or mixed form (Clare et al., 2019). More broadly, non-drug interventions have hardly been evaluated by controlled trials in frontotemporal dementias (Shinagawa et al., 2015).

In the behavioural variant, disinhibition can put the other members of a group in difficulty, and apparent indifference can hurt them: the group is therefore discussed case by case. The strategies proposed, drawn mainly from clinical experience, rely on the behaviours specific to the disease and on the abilities the person retains, and they go together with support for the carer, whom these behaviours put under great strain (Shinagawa et al., 2015).

In the aphasias, work on language belongs to the speech and language therapist. A group based on conversation sets the person up to fail if the activities are not adapted: written or picture-based materials, answers given by choosing or by a gesture. Individual rehabilitation, which starts from concrete goals chosen by the person, adapts more easily, bearing in mind that it was evaluated in other forms.

Other causes

Other causes are rarer, and some of them change what is done.

• Alcohol-related brain damage is one of them, including Korsakoff syndrome, due to a lack of vitamin B1. It affects people younger than the other dementias, often isolated, and it can improve at least partly if abstinence is maintained, unlike degenerative diseases (Ridley et al., 2013).
• Normal pressure hydrocephalus, an enlargement of the cavities of the brain that contain the cerebrospinal fluid, combines walking difficulties, urgent needs to pass urine and a slowing of thought. It is looked for because a shunt, that is, a small tube placed by a neurosurgeon to drain off some of this fluid, improves the difficulties in a large proportion of carefully selected people (Williams and Malm, 2016).
• Dementia can also occur following certain infections, such as HIV infection, repeated head injuries or nutritional deficiencies, which the World Health Organization (2026) lists among its causes.

A very rapid worsening, over a few weeks or a few months, is not the usual course of the common causes. It calls for urgent medical assessment, because it may stem from an unusual form of a degenerative disease, from a prion disease such as Creutzfeldt-Jakob disease, due to an abnormal protein that spreads through the brain, but also from diseases that can be treated, such as certain forms of autoimmune encephalitis, inflammations of the brain caused by the immune system (Geschwind, 2016).

What the cause changes for this programme

The table summarises what precedes.

Cause	What is affected first	Usual course	What you adapt
Alzheimer's disease	Learning new information	Gradual, over years	Compensate for memory: errorless learning, external aids
Vascular dementia	Speed of thought, attention, organisation	In steps after a stroke, or gradual	Slow down, one instruction at a time; look for apathy and depression
Mixed form	Both profiles combined	Variable, depending on the share of each type of damage	Add together the adjustments for both forms
Lewy body dementias	Attention, visual perception, fluctuating alertness	Gradual, with fluctuations	Sessions at the best time, simple visual materials; unusual changes and new hallucinations reported to the doctor
Behavioural variant frontotemporal dementia	Social behaviour, initiative, empathy	Gradual, most often before the age of 65	Strategies based on the person's habits and abilities, support for the carer; group case by case
Primary progressive aphasias	Language	Gradual	Speech and language therapy; written or picture-based materials, answers by choosing or by a gesture

When the report does not specify the cause. It sometimes speaks only of "cognitive impairment" or of "dementia". Ask the doctor what was concluded, rather than deducing it from what you observe.

When what you observe does not fit. Hallucinations, marked fluctuations, repeated falls, a change in behaviour in the foreground or language deteriorating on its own, in a person whose diagnosis is given as Alzheimer's disease, are noted precisely and passed on to the doctor. These observations may lead to the diagnosis being reviewed and, with it, what is done, in particular regarding medication (McKeith et al., 2017).

4. Five pictures not to be confused

The neighbouring manual describes these pictures in detail (its section 4). Only what decides entry into this programme is covered here.

1. Memory complaint without objective decline

What you observe. A person worried about their forgetfulness, whose daily life has not changed and whose assessment is normal.

What it implies. Neither the group nor rehabilitation is indicated. If anxiety predominates, that is what is treated; the public programme The fear of being ill: health anxiety can be useful.

2. Mild neurocognitive disorder

What you observe. An objective decline, with independence preserved at the cost of effort.

What it implies. This programme has not been evaluated at this stage. Goal-oriented rehabilitation can be discussed for a specific difficulty, making clear that the data come from the next stage.

3. Mild to moderate dementia

What you observe. A clear decline, which affects complex activities (paperwork, money, journeys), then certain basic activities. The person can still follow a conversation, express a preference and learn, slowly, through repetition.

What it implies. This is the indication for this programme. The Haute Autorité de santé, the French health authority that publishes good practice recommendations (section 13), places the mild stage, as a rough guide, around a score of 21 to 25 on the Mini-Mental State Examination and the moderate stage around 16 to 20, describing each stage first by its clinical markers and by independence (Haute Autorité de santé, 2018). It then describes a moderately severe stage, around 10 to 15, marked by the beginning of dependence. The original cognitive stimulation trial included people down to a score of 10 (section 2): at this intermediate stage, what decides is the ability to follow a group conversation.

4. Severe dementia

What you observe. Dependence for the activities of daily living and reduced language.

What it implies. The group and rehabilitation are no longer suitable. The Haute Autorité de santé (2018) then recommends adapted, sensory stimulation, avoiding overstimulation; the work focuses on comfort and on the carer.

5. Acute confusion, or delirium

What you observe. Over a few hours or a few days, a person becomes disoriented, inattentive, drowsy or agitated, with fluctuations during the day.

What it implies. A medical emergency, never an indication for this programme; in a person with dementia, a sudden worsening is confusion until proven otherwise (section 10).

The two sorting questions

"What do you still do on your own, and what do you do with help?" The answer places the stage through independence.

"Would you like to meet other people to talk and do activities, or to work on one particular thing that bothers you?" It checks consent, and already points towards one of the two modules.

5. What dementia does to thinking, and what it leaves

What is affected

Memory for recent events. In Alzheimer's disease, this is the earliest difficulty: retaining what has just been said, an appointment, where one has put an object. It explains the repeated questions and the lost objects.

Attention. Following a conversation with several people, doing two things at once, resisting background noise becomes costly, and fatigue sets in quickly.

Executive functions, that is, the ability to organise an action into steps, to plan, to change strategy when the first one fails. They explain why a recipe, paperwork or an unfamiliar journey become impossible while each single action remains possible.

Language and orientation. The right word does not come, and the person finds their bearings less well in time, then in space.

What is spared for a long time

It is on this side that the whole programme rests.

Long-held skills and learned actions. Playing an instrument, folding laundry, trimming a hedge: these skills are often preserved long after the person can no longer say how they learned them.

The possibility of learning, provided it is done differently. People with early dementia can learn a specific piece of information or procedure when they are prevented from making mistakes during learning (Clare and Jones, 2008) and when they are asked to retrieve the information at longer and longer intervals, what is called spaced retrieval (Oren et al., 2014). These benefits are not found in everyone or for every task, and section 44 says what can be expected of them.

Old memories. Some memories of youth and adulthood remain accessible for a long time, which makes reminiscence a support for conversation (section 45).

Emotions and preferences. The person perceives tone, patience or impatience, being consulted or being ignored, and they keep tastes, opinions and values. That is why the group asks for opinions rather than correct answers (section 43).

What this implies for the programme

There is no attempt to restore through exercise what has been lost. The programme relies on what remains: opinions rather than facts, a few useful errorless learnings, external aids for what memory no longer carries, and activities that draw on long-held skills.

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